G     000  005  695     2^ 


PRACTICAL  TREATISE 


Diseases  of  Women. 


BY 

T.  GAILLAKD  THOMAS,  M.D., 

PROFESSOR  OP  OBSTETRICS  AND  DISEA.SKS  OP  WOMEN  ANO  CHlLDRSiN  IN  THE  COLLEGE  OP 

PHYSICIANS  AND  SURGEONS,  NEW  YORK; 

SURGEON    TO   THE    NEW    Y'ORK    STATE   WOMAN'S    HOSPITAL;    CONSULTING   PHYSICIAN    TO   THE 

NURSERY'  AND  CHILD'S  HOSPITAL,  NEW  Y^ORK  ;  TO  ST.  MARY'S 

HOSPITAL  FOR  WOMEN,  BROOKLYN  ; 

HONORARY  FELLOW    OP   THE   OBSTETRICAL   SOCIETY    OK    LONDON: 

CORRESPONDING  MEMBER  OP  THE  OBSTETRICAL  SOCIETY  OF  BERLIN,  OP  THE  GYN^COLOG  ICAL 

SOCIETY  OP  BOSTON,  OP  THE  MEDICAL  SOCIETY  OF  LIMA,  PERU,  OF  THE  OB.-.TETRICAL 

SOCIETY'  OP  PHILADELPHIA;   HONORARY  MKMBER  OF  THE 

LOUISVILLE  OBSTETRICAL  SOCIETY. 


FOURTH  EDITION,  THOROUGHLY  REVISED. 


WITH  ONE  HUNDRED  AND  NINETY.ONE  ILLUSTRATIONS  ON  WOOD. 


PHILADELPHIA. 
HEIi^RT    C.     LE 

1878. 


A 


Entered  according  to  act  of  Congress,  in  the  year  1874,  by 

HENRY     C.     LEA, 

in  the  Office  of  the  Librarian  of  Congress.     All  rights  reserved. 


Sherman  &  Co.,  Printei 

Philadelphia. 


i.;:-.odicaI 
Libraiy 


T3t7^ 

I  in 


TO 


JOHIVT  T.  METCALFE,  M.D., 

PROFESSOR  OF  CLIMCAL  MED1C1>'E  IN  THE  COLLEGE  OF  PHYSICIANS  AND  SURGEONS, 

NEW  YORK  : 


IN  TOKEX  OF  ADMIRATION  OF  HIS  PROFESSIONAL  SKILL; 


OF  GRATITUDE  FOR  NUMBERLESS  FAVORS  RECEIVED  DURING  LONG  YEARS 


EOI 
^  OF  AN  INTERCOURSE, 


UNINTERRUPTED  IN  ITS  HARMONY  AND  PLEASANT  RELATIONS; 

AND 

OF    THE    WARMEST    PERSONAL    AFFECTION, 
IS    INSCRIBED    BY    HIS    FRIEND, 

THE    AUTHOR. 


B^iRSRO 


PREFACE  TO  THE  FOURTH  EDITION. 


In  presenting  tliis,  the  fourth  edition  of  his  treatise  on  the 
Diseases  of  Women,  the  author  desires  to  express  the  great  gratifi- 
cation which  he  has  felt  at  the  cordial  reception  accorded  to  the 
work  hy  his  professional  brethren,  as  shown  by  the  exhaustion  of 
three  large  editions  within  five  years,  the  translation  of  the  work 
into  German,  and  preparations  now  on  foot  to  render  the  present 
edition  into  French  and  Italian.  Stimulated  by  this,  he  has  spared 
no  pains  in  the  revision  to  make  tlie  work  a  faithful  exponent  of 
the  most  advanced  condition  of  gynecology.  Many  portions  have 
been  virtually  rewritten,  and  the  whole  has  received  the  most  care- 
ful attention.  The  series  of  illustrations  has  been  reduced  by  the 
omission  of  many  which  seemed  to  be  superfluous,  while  a  number 
of  new  ones  have  been  introduced  which  it  is  hoped  will  more 
thoroughly  elucidate  the  text. 

To  one  point  in  the  work  the  author  would  call  the  attention  of 
the  reader.  Some  of  the  manipulations  recommended  by  him  will 
be  found  diflicult  of  accomplishment  by  the  practitioner  who 
employs  the  cylindrical  speculum  or  others  which  are  applied  in 
the  dorsal  position.  As  examples,  may  be  mentioned  the  use  of 
the  intra-uterine  stem  with  supporting  anteversion  pessary,  and 
the  uterine  probe.  Introduced  through  Sims's  speculum,  they  are 
easily  managed ;  employed  in  any  other  way,  their  use  is  attended 
by  difliculties. 

It  may  ver^^  naturally  be  asked  why  the  author,  knowing  as  he 
does  that  the  dorsal  method  of  speculum  examination  almost 
universally  prevails,  teaches  from  the  standpoint  of  the  lateral  or 
Sims's  method?    He  answers  tlie  question  in  all  candor  in  this  way, 

(V) 


Vi  PEEFACE    TO    THE    FOURTH    EDITION. 

He  looks  upon  the  introduction  of  the  lateral  method  of  speculum 
examination  as  a  great  advance  in  gynecology;  he  regards  it  as  a 
method  which  puts  him  who  practises  it  upon  a  decided  vantage- 
o-round  over  him  who  employs  the  dorsal  method  ;  and  he  confi- 
dently looks  forward  to  the  day  when  the  great  superiority  of  the 
levator  perinei  speculum  will  cause  it  to  supersede  all  others.  He 
freely  acknowledges  that  in  this  estimate  he  may  be  entirely  in 
error;  but  so  strong  are  his  convictions  that  he  w^ould  be  recreant 
to  them  did  he  speak  less  decidedly.  In  the  Woman's  Hospital, 
of  this  city,  with  a  surgical  staff  of  twelve,  this  plan  is  universally 
adopted ;  and  an  opportunity  of  demonstrating  its  advantages 
always  aifords  pleasure  to  the  surgeons  of  the  institution.  Time, 
the  test  of  the  value  of  all  things,  will  settle  this  matter,  and  the 
author,  with  the  small  minority  which  believes  as  he  does,  is 
perfectly  wnlling  to  abide  its  verdict. 

In  the  preparation  of  this  edition  for  the  i^ress  the  author  has 
been  greatly  aided  by  three  of  his  friends,  to  whom  he  offers  his 
sincere  thanks— Drs.  S.  Beach  Jones,  Jr.,  James  B.  Hunter,  and 
Matthew  D.  Mann. 

New  York,  June,  1874. 


CONTENTS. 


CHAPTER  I. 

Historical  Sketch  of  Gynecology 


PAGE 

17 


CHAPTER  11. 

The  Etiology  of  Uterine  Disease 

Want  of  Air  and  Exercise        .... 

Excessive  Development  or  the  Nervous  System 

Improprieties  of  Dress 

Imprudence  during  Menstruation 
Imprudence  after  Parturition  .... 
Prevention  of  Conception  and  Induction  of  Abortion 
Marriage  with  Existing  Uterine  Disease  . 


43 
44 
45 
46 
48 
49 
.51 
52 


CHAPTER  III. 

Diagnosis  of  the  Diseases  of  the  Female  Genital  Organs          ...  54 

Rational  Signs  of  these  Diseases 57 

Management  of  Patient  during  Physical  Examination       ...  59 

Means  of  Physical  Diagnosis 60 

Anaesthesia 60 

Vaginal  Touch 60 

Conjoined  Manipulation,  or  Bimanual  Palpation       ....  62 

Abdominal  Palpation         .........  63 

Abdominal  Palpation  conjoined  with  the  use  of  the  Sound        .         .  63 

Inspection 64 

Rectal  Touch 64 

Simon's  Method  of  Rectal  Exploration 65 

Yesico-rectal  Exploration 65 

The  Speculum 65 

The  Uterine  Sound  and  Probe 73 

Tents 77 

The  Exploring  Needle 83 

The  Aspirator 83 

The  Microscope 84 

Auscultation  and  Percussion      ........  85 

Recapitulation  of  Means  for  exploring  Pelvic  Viscera  and  Tissues  .        .  85 

( vii ) 


VUl 


CONTEXTS. 


CHAPTEE  IV. 


Diseases  of  the  Yulva 
Normal  Anatdiny 
Vulvitis    . 

Purulent  Vulvitis 

Follicular  Vulvitis 

Gangrenous  Vulvitis 
Cyst  and  Abscess  of  the  Vulvo- Vaginal 
Eruptive  Diseases  of  the  Vulva 
Phlegmonous  Inflammation  of  the  Labia 
Rupture  of  the  Bulbs  of  the  Vestibule 

Pudendal  Hemorrhage 

Pudendal  Hematocele 
Pudendal  Hernia 
Hydrocele 
Pruritus  Vulvae 
Hyperajsthesia  of  the  Vulva 
Irritable  Urethral  Caruncle 
Urethral  Venous  Angioma 
Prolapsus  Urethra 
Coccyodynia     . 
Tumors  of  the  Vulva 


Gland 
Maj 


PAG  "5 

8G 

80 

87 

87 

83 

92 

93 

95 

90 

97 

98 

90 

102 

104 

100 

114 

110 

110 

119 

120 

124 


Rlptcre  of  the  Perineum 


CHAPTER  V 


125 


Vaginismus 


CHAPTER  VI. 


141 


CHAPTER  VII. 

Taoinitis 150 

Simple  Vaginitis 1,51 

Specific  Vaginitis  or  Gonorrhoea 154 

Granular  Vaginitis 15S 

CHAPTER  VIII. 

Atresia  Vaginae     ............  101 


CHAPTER  IX. 
Prolapsus  Vagina  and  Vaginal  Herni^e 
Prolapsus  Vaginae 
Vaccinal  ITernife 

Cystoccle  . 

Rectiicele  . 

Enterocele 

Treatment  of  Vaginal  Prolapse  and  Hernia 


100 
160 
ITA 
173 
174 
175 
170 


COoSTTENTS. 


IX 


CHAPTER  X. 

FiSTUL.E  OF  THE  FeMALE  GeNITAL  OrGAXS 

Urinary  FistuliB 

Yesico- Vaginal  Fistula 

Urethro-Yagi  al  Fistula   . 

Yesico-Uterine  Fistulae 

Yesico-Utero-Yaginal  Fistulae  . 
Treatment 

Ciuiterizatiou     ..... 

Suture 

Sims's  Operation 
Simon's  Operation 

Elytroplasty      ..... 

Closure  of  the  Yagina 
Urinary  Fistulis  requiring  Special  Treatment 

Yesico-Uterine  Fistulas 

Yesico- Utero-Yaginal  Fistulte  . 

Fistulae  with  Extensive  Destruction  of  the  Base  of  the  Bladder 


PAGK 

178 
178 
179 
179 
179 
179 
191 
191 
192 
192 
199 
206 
207 
209 
209 
210 
210 


CHAPTER  XI. 

Fecal  Fistul.t:         . 

Entero-Yaginal  Fistulae 

Simple  Yaginal  Fistulte 

CHAPTER  Xll. 

Gexeral  Coxsideratioxs  upox  Uterixe  Pathology  axd  Treatmext     . 


212 
21.5 
215 


216 


CHAPTER  XIII. 
Acute  Exdometritis 229 


CHAPTER  XIY. 
Chroxic  Cervical  Exdometritis     .         .         .         . 


236 


CHAPTER  XY. 

Chroxic  Corporeal  Exdometritis 254 

Injections  into  the  Uterine  Cavity 266 

CHAPTER  XYI. 

Areolar  Hyperplasia  of  the  Uterus — The  so-called  Chroxic  Parexciiy- 

matous  Metritis        .         .         .         .         .         .         .         .         .         .         .274 

Yaginal  injections 304 

CHAPTER  XYII. 

Graxclar  axd  Cystic  Deoeneratiox  of  the  ( Jervix  Uteri    ....  309 

Granular  Degeneration  of  the  Cervix 309 

Cystic  or  Follicular  Degeneration  of  the  Cervix 316 


CONTEXJS. 


CHAPTER  XYIII. 
Sypuilitic  Ulcer  of  the  Cervix  Uteri  .         .         ,         . 

CHAPTER  XIX. 
General  Coxside ration  upox  Displacemexts  of  the  Uterus 


CHAPTER  XX. 

Ascent  and  Descent  of  the  Uterus 

Ascent  of  the  Uterus 

Descent  or  Prolapsus  of  the  Uterus 

Methods  of  Replacing  the  Uterus 

Methods  of  Sustaining  the  Uterus 

Perineorrhaphy 

Elytrorrhaphy  .... 

Sinis's  Operation  of  Elytrorrhaphy 

Emmet's  Operation  of  Elytrorrhaphy 

Thomas's  Operation  fur  Narrowing  the  Vagina 


CHAPTER  XXI 


Anteversiox  of  the  Uterus   . 
Means  for  Reduction         .... 
Means  for  Retaining  the  Uterus  in  Position 
Pessaries 


CHAPTER  XXII 


Retroversion  of  the  Uterus 
Methods  of  Reduction 
Methods  of  Retention 
Pessaries  .... 


CHAPTER  XXIII. 


Flexioxs  of  the  Uterus 


CHAPTER  XXIV. 
Anteflexiox  of  the  Uterus  ..... 
Treatment  •••<.... 
Means  of  Obviating  the  Consequences  of  Flexion 


CHAPTER  XXV. 


Retroflexion''  of  the  Uterus 

Treatment 

Latcroflexion    . 


pagk 
318 


320 


327 
327 
328 
342 
343 
340 
350 
351 
352 
354 


357 
364 
365 
366 


373 

378 
379 

383 


390 


402 
405 
412 


415 
418 
422 


CONTEXTS.  xi 


CHAPTER  XXVI. 


Intersiox  of  the  Uterus 

Methods  of  Checking  HemoiThage,  the  uterus  being  left  in  situ 

Methods  of  Replacing  the  Uterus 

Thomas's  Operation  ....... 

Methods  of  Amputating  the  Uterus         ..... 


PAGK 

423 
433 
434 
.  440 
449 


CHAPTER  XXVII. 

Periuterixe  Cellulitis  .  452 

CHAPTER  XXVIII. 
Pelvic  Peritonitis 4G5 

CHAPTER  XXIX. 
Pelvic  Abscess 481 

CHAPTER  XXX. 
Pelvic  Hematocele         . 488 

CHAPTER  XXXI. 

Myo-Fibromata  or  Fibroid  Tu.mors  of  the  Uterus 499 

Gastrotomy 518 

CHAPTER  XXXII. 

Cysto-Fibromata  or  Fibro-Cystic  Tumors  of  the  Uterus      ....     523 

CHAPTER  XXXIII. 

Uterixe  Polypi 530 

CHAPTER  XXXIV. 

Sarcoma  of  the  Uterus .     539 

CHAPTER  XXXV. 

Cancer  of  the  Uterus 543 

Epithelial  Cancer 549 

Cancer  of  the  Body  of  the  Uterus 564 

CHAPTER  XXXVI. 

Diseases  Re.sulting  from  Retention  and  Alteration  of  the  Fcetal  En- 
velopes    .............  574 

Uterine  Moles 574 

Cystic  Degeneration  of  the  Chorion,  or  Uterine  Hydatids        ....  576 


Xll 


CONTENTS. 


CHAPTER  XXXTIL 

Dysmenorrh(ea 

Neuralgic  Dysmenorrha?a 

Congestive  or  Inflammatory  Dysnieiiorrhoea 

Obstructive  Dysmenorrhcea 

Membranous  Dysmenorrhoca     . 

Ovarian  Dysmeuorrhoea    .... 

CHAPTER  XXXVIII. 
Menorrhagia  and  Metrorrhagia  .... 


PAGE 

579 

582 
584 
586 
593 
600 


602 


AUENORRHQCA 


CHAPTER  XXXIX. 


610 


Leocorru(ea 


CHAPTER  XL. 


618 


Sterility 


CHAPTER  XLL 


624 


CHAPTER  XLII. 

Amputation  of  the  Neck  of  the  Uterus 
Operation  by  Bistoury  or  Scissors    .         .         .         . 

Operation  by  Ecraseur      ...... 

Operation  by  Galvauo-Cautery         .         .         .         . 


629 
631 
631 
632 


CHAPTER  XLIIL 


Diseases  of  the  Ovaries 
Absence  .... 
Imperfect  Development  . 
Atrophy  .... 
Ovarian  Apoplexy  , 
Displacement  . 
Ovaritis  .... 
Acute  Ovaritis 

Chronic  Ovaritis 


634 

638 
638 
641 
642 
643 
644 
644 
648 


CHAPTER  XLIT. 

Ovarian  Tumors 

Carcinoma 

Fibroma  or  Fibrous  Tumor 

Cysto-Carcinoma 

Cysto-Fibroiiia  or  Cysto-Sarcoma 

Dermoid  Cysts 

Colloid  Degeneration 


651 
653 
655 
656 
657 
658 
660 


CONTENTS.  xiii 


CHAPTER  XLV. 

PAOK 

Ovarian  Ctsts  and  Ctstomata 662 

Cystsof  the  Broad  Ligaments 677 

Parasitic  or  Hydatid  Cysts 078 

Tubal  Dropsy 679 

Subperitoneal  Cysts          .         .         •        .        ,         .         .    '     .         .         .         .  680 

Cysts  connected  with  the  Spinal  Cor,d      . 681 

CHAPTER  XLVL 

Ovariotomy ,..  717 

Vaginal  Ovariotomy 732 

Abdominal  Ovariotomy 738 

CHAPTER  XLVIL 

Diseases  of  the  Fallopiax  Tubes 764 

CHAPTER  XLVIIL 

Chlorosis         .«.,.-.......  770 


LIST  OF   ILLUSTRATION'S. 


PIG. 

1.  Ancient  Valvular  Specula  (Scultetus) 

2.  Practice  of  Conjoined  Manipulation  (Sims) 

3.  Fergussou's  Speculum      .... 

4.  Thomas's  Telescopic  Speculum 

5.  Cusco's  Speculum     ..... 

6.  Neugebauer's  Speculum  .... 

7.  Sims's  Speculum       ..... 

8.  Sims's  Depressor       ..... 

9.  Nott's  Speculum 

10.  Hunter's  Speculum  .... 

11.  Thomas's  Modification  of  Sims's  Speculum 

12.  Nurse  holding  Sims's  Speculum  (Sims)     . 

13.  Sounds  of  Simpson  and  Sims  compared     . 

14.  Thomas's  Elastic  Probe    .... 

15.  A  Sponge  Tent 

16.  A  Sea-tangle  Tent  .... 

17.  Tenaculum  for  fixing  the  Uterus 

18.  Introduction  of  a  Tent  (Sims) 

19.  Dieulafo3''s  Aspirator       .... 

20.  Follicular  Vulvitis  (Huguier) 

21.  Plexus  of  Veins  of  the  Vestibule  (Kobelt; 

22.  Perineal  body  perfect       .         .         . 

23.  Perineal  body  removed  by  rupture 

24.  Perineum  improperly  repaired 

25.  Thomas's  Tooth  Forceps 

26.  Slightly  Curved  Scissors 

27.  Emmet's  Scissors  sharply  curved 

28.  Profile  view  of  Perineum 

29.  Surface   denuded,   and   Sutures  in   position 

Eupture 

30.  Quill  Sutures  in  place      .... 

31.  Sphincter  perfect      ..... 

32.  Sphincter  ruptured  and  spj'ead  out 

33.  Twisting  of  Sutures  for  repair  of  Sphincter 

34.  Sutures  twisted        ..... 

35.  Ruptured  Bowel,  Sphincter  and  Sutures  in  position 

36.  Surface  denuded,  and  Sutures  in  position  in  complete  Perineal  Rupture 

37.  Pubo-coccygeus  Muscle  (Savage)     . 

38.  Sims's  Vaginal  Dilator 

(XV) 


in   Operation   for  Partia 


XVI 


LIST    OF    ILLUSTRATIONS. 


pia. 
39. 
40. 

41. 

42. 
43. 

44. 
45. 
46. 
47. 
48. 
49. 
50. 
51. 
52. 
53. 
54. 
55. 
56. 
57. 
58. 
59. 
60. 
61. 
62. 
63. 
64. 
65. 
66. 
67. 


68. 
69. 
70. 
71. 

72. 
73. 
74. 
75. 
76. 
77. 

78. 
79. 
80. 
81. 

82. 


itis. 


or  Su 


Two 


pposi- 


Filiform  Papillae  of  Vagina  (Kilian) 

Epithelium  in  all  Stages  of  Development,  in  Simple  Yagin 

liiindred  and  twenty  diameters  (T.  Smith)     . 
Hard-rubber  Tube  with  Piston,  for  placing  Medicated  Cotton 

tories  in  the  Vagina 

Varieties  of  Urinary  Fistulae 

Curved  Scissors 

Bistoury  for  paring  edges  of  Fistula        .... 
Paring  the  Edges  (Wieland  and  Dubrisay)      . 

Showing  bevelling  of  edges 

Sims's  Sponge-holder  with  Handle  nine  inches  long  (Sims) 

Needle  held  in  Forceps 

Course  of  the  Needle 

Passing  the  Needle  (Wieland  and  Dubrisay)    . 

Twisting  the  Sutures 

Fulcrum  for  supporting  Wire  while  it  is  twisted 
Fork  with  blunt  points  to  aid  the  Passage  of  Sutures 

Hook  for  Engaging  Needle 

Sutures  Twisted  (Wieland  and  Dubrisay) 

Sims's  Sigmoid  Catheter 

Simon's  position  for  Vesico-vaginal  Fistula  (Simon) 
Vivifying  the  edges  of  the  Fistula  (Simon) 

Sutures  in  Position  (Simon) 

Obliteration  of  the  Vagina  (Simon)  .... 

The  Cervix  is  slit  to  expose  the  Fistula  above,  and  Sutures  are  passed 
Anterior  Lip  of  Fistula  united  to  Anterior  Lip  of  Cervix  (Simon) 
Anterior  Lip  of  Fistula  united  to  Posterior  Lip  of  Cervix  (Simon) 

Examination  for  Fecal  Fistulae .         . 

Showing  Dividing  Line  between  Body  and  Cervix  of  Uterus 

Showing  the  Site  of  Chronic  Cervigal  Endometritis         .         .         .         . 

Villi  of  Canal  of  the  Cervix  Uteri,  covered  by  Cylindrical  Epithelium 

and     containing     Looped    Bloodvessels.        One     hundred    diameters 

(T.Smith) 

Syringe  for  removing  Cervical  Mucus 

Rod  eight  or  nine  inches  long,  wrapped  with  cotton 

Budd's  Elastic  Probe       ...... 

Lente's  Silver  Caustic  Probe  .... 

Lente's  Cup  for  Fusing  Nitrate  of  Silver 

Silver  Probe  with  Cotton  wrapped  around  it  and  Thread  attached 

Sims's  Curette,  representing  the  Angles  at  which  it  may  be  Bent 

Showing  the  Site  of  Corporeal  Endometritis 

Wylie's  Cervical  Speculum  with  Probe  passing  through  it 

Molesworth's  Double  Canula  and  Bulb  Syringe  for  injecting  the  Uterine 

Cavity 

Showing  the  Site  of  Cervical  Hyperplasia 

Showing  the  Site  of  (Corporeal  Hyperplasia 

Bacheller's  Skirt  Supporter     . 

Buttles's  Spear-poiuted  Scarificator 

Hard-rubber  Cylinder  for  Dry  Cupping  the  Cervix  Uteri 


PAGE 
150 

153 

160 
179 
193 
193 
194 
194 
194 
196 
196 
196 
197 
197 
197 
197 
198 
198 
201 
203 
204 
208 
210 
210 
211 
214 
223 
237 


238 
247 
248 
249 
2.50 
2.50 
251 
252 
254 
264 

272 
290 
290 
301 
303 
304 


LIST    OF    ILLUSTEATIOjS'S. 


XVll 


FIG. 

83.  Davidson's  Syringe 

84.  Molesworth's  Vaginal  Syringe 

85.  Cystic  Degeneration  of  the  Cervix 

86.  Diagram  representing  the  Three  Degrees  of  Prolapsus  Uter 

87.  Cutter's  Prolapsus  Pessary  in  position     . 

88.  Prolapsus  Pessary  with  Abdominal  Support 

89.  Uterus  fixed  by  Sound  (Sims) 

90.  Emmet's  Operation  of  Elytrorrhaphy 

91.  Dilating  Forceps  for  separating  the  Bladder  and  Yagina 

92.  Clamp  with  Teeth  for  compressing  Wound  in  Yagina 

93.  Normal  position  of  Uterus  (Breisky) 

94.  The  Degrees  of  Anteversion     . 

95.  Abdominal  Pad  of  Wood  or  Cork 

96.  Thomas's  Anteversion  Pessary  closed 

97.  Thomas's  Anteversion  Pessary  open 

98.  Thomas's  Anteversion  Pessary  (2d  variety)  closed 

99.  Thomas's  Anteversion  Pessary  (2d  variety)  open 

100.  Plitchcock's  Anteversion  Pessary 

101.  Anteversion  Pessary  with  Bulb  supporting  Uterus 
102. 

103.  Graily  Hewitf  s  Anteversion  Pessar; 

104.  Retroversion  of  the  Uterus 

105.  The  Degrees  of  Retroversion 

106.  Sims's  Uterine  Repositor 

107.  Tampon  for  Retroversion 

108.  Hoffman's  Pessary 

109.  Hodge's  Pessary 

110.  Albert  Smith's  Pessary    . 

111.  Modiiication  of  Cutter's  Pessary 

112.  Cutter's  Pessary 

113.  Hewitt's  Pessary 

114.  Meigs's  Ring  Pessary 

115.  The  Uterus  descending  changes  its  Axis 

116.  Anteflexion 

117.  Yarieties  of  Anteflexion 

118.  Anteflexion  Pessary  being  introduced 

119.  Anteflexion  Pessary  after  introduction 

120.  Hurd's  Pessary  ;  Uterus  not  yet  in  it 

121.  Hurd's  Pessary  ;  Uterus  in  position 

122.  Intra-Uterine  Stem  and  Pessary  for  Anteflexion 

123.  Creation  of  New  Uterine  Axis 

124.  Sims's  Knife 

125.  Posterior  Section  <if  the  Cervix  (Sims)     . 

126.  Double  Scissors  for  Incision  of  the  Cervix 

127.  Thomas's  Retroflexion  Pessary 

128.  Hurd's  Pessary 

129.  Hurd's  Pessary  ;  Retroflexed  Uterus  in  position 

130.  Intra-Uterine  Stem  for  Retro-  and  Lateroflexion 

131.  Partial  Inversion 

B 


XVlll 


LIST    OF    ILLUSTRATIONS. 


no. 

132. 

133. 

134. 

135. 

136. 

137. 

138. 

139. 

140. 

141. 

142. 

143. 

144. 

145. 

146. 

147. 

148. 

149. 

150. 

151. 

152. 

153. 

154. 

155. 

156. 

157. 

158. 

159. 

160. 

161. 

162. 

163. 

164. 

165. 

166. 

167. 

168. 

169. 

170. 

171. 

172. 

173. 

174. 

175. 

176. 

177. 

178. 

179. 

180. 


Abdomen 


Polyp 


Complete  Inver.sion 

Polypus    . 

Inversion 

FiWrous  Polypus 

Partial  Inversion 

Rai)i(l  Reduction  by  White's  Method       . 

Replacement  of  Uterus  by  Dilatation  through 

Dilator  to  be  used  after  Abdominal  Section 

Represent  iu,u'  the  Roof  of  the  Pelvis 

Peritoneal  Hematocele  (Barnes) 

Uterine  Fibroma  (Billroth) 

Mulesworth's  Cervical  Dilator 

Aveling's  Polyptome        .... 

Neiaton's  Forceps 

The  Ecraseur,  straight  and  curved   . 

The  Ecraseur  at  work       .... 

Elastic  Whalebone  Probe 

Submucous  Fibroid  .... 

The  Fibre  Cell  characteristic  of  Fibro-cystic  Tumors 

Cellular  Polypus  attached  within  the  Cervix  Uteri 

Clandular  Polypus 

A  Submucous  Fibroid  being  transformed  into  a  Fibrous 

Simpson's  Polyptome 

Hicks's  Wire  Rope  Ecraseur    .        .        .        *         . 

Cancer  of  Mamma ;  Stroma  and  Cells  (Billroth) 

Connective  Tissue  Framework  of  Cancer  of  Mamma  (Bi 

Flat  Epithelial  Cancer  of  Cheek  (Billroth)       . 

Transverse  Section  of  a  Vegetating  Epithelioma  (Virch 

Yegetating  Epithelioma  (Simpson) 

Simon's  Scoop 

Cystic  Degeneration  of  Chorion  (Boivin  and  Duges) 
Priestly's  Dilator  for  the  Cervix 
Simpson's  Ilysterotome    . 
Stohlman's  Hysterotome 
White's  Hysterotome 
Dysmenorrhoeal  Membrane  (Coste) 
Curette  of  Wire  without  Cutting  Edge 
Syringe  for  Dry  Cupping  the  Cervix- 
Galvanic  Pessary     .... 
Vaginal  Leucorrhoca  under  the  Microscope  (Smith) 
Cervical  Leucorrhoca  under  the  Microscope  (Smith) 

Conoidal  Cervix  (Sims) 

Byrne's  Galvano-caustic  Battery      .... 
Microscopic  Appearance  of  Ovarian  Fluid  (Drysdale) 

Tubal  Dropsy  (Hooper)  

Trocar  and  Canula  for  tapping  Ovarian  Cysts 


Maisonneuve's  Trocar  and  Permanent  Canula  (Wieland  and  Dubrisay) 
Bozeman's  Securing  Apparatus 


rotl: 


LIST    OF    ILLUSTRATIONS. 


XIX 


FIG. 

181. 
182. 
183. 
184. 

18,5. 
186. 
187. 
188. 
189. 
190. 
191. 


Spencer  "Wells's  Trocar  and  Canula 

Dawson's  Temporary  Clamp 

Spencer  Wells's  Clamp     . 

French  Clamp 

Dawson's  Permanent  Clanip 

Storer's  Clamp-shield 

Thomas's  Drainage  Tube 

Record  of  Temperature  in  a  case  of  Ovar 


Tubal  Dropsy  (Boiviu  and  Duges) 


iotomy 


PAGE 

746 
748 
749 
75U 
750 
752 
756 
760 
761 
761 
769 


THE 


DISEASES    OF    WOMEN. 


CHAPTER    I. 

HISTORICAL  SKETCH  OF  GYNECOLOGY. 

At  the  present  day,  when  so  much  attention  is  being  paid  to 
the  diseases  peculiar  to  women,  i-t  becomes  almost  necessary  that  a 
chapter  upon  the  history  of  the  subject  should  precede  others  of  a 
more  practical  character  in  a  sj-stematic  work.  A  knowledge  of 
what  has  been  accomplished  in  reference  to  any  subject,  and  what 
was  known  concerning  it  in  previous  ages,  cannot  fail  to  interest 
the  student,  and  render  him  more  capable  of  appreciating  recent 
advances.  In  this  way,  too,  a  taste  for  the  study  of  ancient  litera- 
ture may  be  inculcated,  and  many  a  useful  hint,  many  a  suggestive 
statement  may  be  met  with  which  will  germinate  for  the  common 
good.  Some  of  the  most  valuable  contributions  to  modern  gyneco- 
logy will  be  found  to  be  foreshadowed,  or  even  plainly  noticed,  by 
the  writers  of  a  past  age,  and  afterwards  entirely  overlooked.  As 
ex9,raples  may  be  cited,  the  use  of  the  uterine  sound,  sponge-tents, 
dilatation  of  the  constricted  cervix,  and  even  the  speculum  itself. 
Indeed,  we  need  not  seek  in  ancient  literature  for  illustrations  of 
this  fact,  for  nowhere  could  a  more  striking  one  be  found  than  that 
of  so  valuable  a  i)rocedure  as  Sims's  operation  for  vesico-vaginal 
fistula  being  fully  described  in  every  detail  in  1834,  and  so  com- 
pletely forgotten  in  twenty  years  as  to  be  accepted  as  entirely  new 
at  the  end  of  that  time. 

There  can  be  no  doubt  that  a  knowledge  of  medicine  as  a  science 
was  possessed  by  the  ancient  Egyptians.  Pliny  informs  us  that 
in  the  times  of  the  Ptolemies  a  medical  school  was  established  at 
Alexandria,  and  dissections  of  the  human  body  legalized.  They 
appear  to  have  been  especially  skilful  as  oculists,  and  it  is  probable 
that  attention  was  paid  to  the  diseases  of  women,  for  among  the 
2  (17) 


18  HISTORICAL    SKETCH 

six  medical  books  in  the  collection  Thoth,  consisting  of  forty-two 
volumes,  one  devoted  to  this  subject  is  particularly  mentioned.^ 
Some  n)odern  Egyptologists  have  even  stated  that  among  the 
hieroglyphics  the  shape  of  the  uterus  can  be  recognized.  As  to 
the  extent  of  Egyptian  knowledge  upon  this  subject  we  have  no 
information,  as  the  literature  of  that  remarkable  people  has  been 
entirely  closed  to  us  until,  within  a  few  years  past,  the  genius  of 
Champollion  has  discovered  a  key  for  its  comprehension.  Hope 
that  the  future  may  bring  forth  a  great  deal  more  than  the  past 
has  done  with  reference  to  it  may  be  further  founded  upon  the  fact 
that  Herodotus-  distinctly  announces  that  specialties  existed  among 
them.  "Here,"  says  he,  "each  physician  applies  himself  to  one 
disease  only,  and  not  more.  Ail  places  abound  in  physicians ;  some 
for  the  eyes,  others  for  the  head,  others  for  the  teeth,  others  for  the 
parts  about  the  belly,  and  others  for  internal  diseases." 

From  Biblical  literature,  which  is  so  abundantly  at  our  command, 
we  learn  almost  as  little  upon  our  subject;  and  from  the  time  of 
Moses,  about  1500  B.  C,  to  that  of  Hippocrates,  400  B.  C,  testimony 
of  precise  knowledge  upon  it  is  almost  entirely  wanting.  This  is 
the  more  astonishing  when  we  bear  in  mind  that  in  the  Talmud 
are  found  evidences  of  a  great  deal  of  knowledge  concerning  the 
Csesarean  section  and  other  subjects  in  obstetrics;  that  in  the  books 
of  Moses  we  tind  intelligent  reference  to  the  hymen  and  menstrua- 
tion ;  and  that  in  the  New  Testament  we  see  St.  Luke,  a  i)hysician 
of  the  time,  recording  the  fact  of  "a  woman  having  an  issue  of 
blood  twelve  years,  which  had  spent  all  her  living  upon  physicians, 
neither  could  be  liealed  of  any,"  etc. 

Although  we  know  so  little  concerning  the  knowledge  possessed 
upon  this  subject  by  those  who  preceded  the  Greeks  in  civilization, 
we  cannot  doubt  that  they  did  much  to  instruct  the  latter  in  this 
as  in  other  departments  of  learning.  History  everywhere  records 
the  fact  that  the  Greeks  were  instructed  by  the  Egyptians,  as  the 
Romans  subsequently  were  by  the  Greeks. 

With  our  present  knowledge  of  the  literature  of  the  most  ancient 
civilizations,  we  must  admit  that  with  the  writings  of  the  Greek 
school,  founded  by  Hippocrates,  commences  the  history  of  gyne- 
cology. Three  volumes  were  written  upon  the  subject  by  authors 
contemporaneous  with  Hippocrates.  They  have  ordinarily  been 
attributed  to  him,  but  Dr.  Francis  Adams,  the  translator  of  the 


'  Abstract  prepared  for  author  by  Charles  Rodenstein,  M.D. 
^  Book  ii,  c.  84. 


f 


OF    GYNECOLOGY.  19 

works  of  Hippocrates  for  the  Sydenham  Society,  declares  them  to 
be,  "ancient  but  spurious, -whose  author  is  not  known."  In  these 
books  the  subjects  of  metritis,  induration,  menstrual  disorders, 
displacements,  etc.,  are  discussed.  Aretseus,  Galen,  Archigenes, 
and  Celsus,  who  probably  lived  in  the  firet  and  second  centuries, 
all  treated  of  gynecology;  the  first  describing  the  vaginal  touch, 
the  varieties  of  leucorrhoea,  and  ulceration  of  the  womb;  while 
the  second  makes  the  first  allusion  on  record  to  the  s[>eculura 
vaginae,  as  being  a  distinct  instrument  from  the  speculum  ani, 
and  the  third  gives  a  description  of  peri-uterine  cellulitis  which 
shows  him  to  have  been  at  least  familiar  with  the  fact  that  the 
tissues  immediately  connected  with  the  uterus  were  liable  to  sup- 
purative inflammation,  the  purulent  products  of  which  discharge 
themselves  through  the  vagina  or  rectum. 

Soranus,  the  younger,  made  important  contributions  to  gyne- 
coloffv.  He  was  educated  at  Alexandria,  went  to  Rome  in  the 
year  220  B.  C,  where  he  wrote  his  celeljrated  work  De  Utero  et 
Pudendo  Muliebri.  He  is  the  oldest  historian  of  medicine,  and  the 
biographer  of  Hippocrates.  His  accurate  descriptions  of  the  sexual 
organs  were  much  admired.  He  takes  pains  to  assure  his  readers 
that  he  dissected  the  human  cadaver,  and  not  monkeys,  as  did 
Galen  and  others.  He  compared  the  form  of  the  uterus  to  a  cup- 
ping-glass, showed  the  relation  of  this  viscus  to  the  ilium  and 
sacrum,  and  made  known  the  changes  which  the  os  undergoes  dur- 
ing pregnancy.  He  attributes  procidentia  to  a  separation  of  the 
internal  membrane  of  the  uterus,  speaks  of  the  sympathy  w^hich 
exists  between  the  womb  and  the  mammary  gland,  and  describes 
the  hymen  and  clitoris. 

From  this  time,  for  centuries,  there  is  abundant  evidence  that 
the  study  of  the  subject  was  pursued  with  vigor,  but  so  many  of 
the  works  of  the  authors  of  those  periods  exist  only  in  fragments, 
and  so  many  are  strongly  suspected  of  being  fictitious,  that  we 
pass  them  over  to  stop  at  the  faithful  compilation  of  Acitius,'  who 
flourished  at  Alexandria  in  the  sixth  century  after  Christ.  His 
works,  compiled  in  the  great  library  at  Alexandria,  contain  a  digest 
of  what  was  known  and  done  by  his  predecessors  and  contempora- 
ries, and  offer  the  fullest  and  most  reliable  evidence  concerning  the 
knowledge  of  those  times.     In  quoting  him,  and  his  immediate 

'  I  am  indebted  to  the  library  of  the  New  York  Hospital  for  an  opportmiity  of 
fully  consulting  this  and  other  rare  works  which  were  accumulated  by  the  late  Dr. 
John  Watson. 


20  HISTORICAL    SKETCH 

successor,  Paulus  JEgineta,  who  was  also  a  compiler,  though  a  far 
less  conscientious  one,  I  must  be  understood  as  recording,  not  the 
views  of  these  individuals,  but  those  entertained  by  physicians  who 
lived  from  the  time  of  Hippocrates  to  the  time  of  their  writing,  a 
period  of  about  one  thousand  years. 

In  his  16th  book  Aetius  treats  of  the  diseases  of  women  in  such 
a  manner  as  to  leave  no  doubt  as  to  his  having  had  a  thorough 
knowledo-e  of  many  disorders  and  means  of  investigation  and  treat- 
ment, which,  being  rediscovered  thirteen  hundred  years  afterwards, 
have,  in  many  instances,  been  regarded  by  us  as  entirely  new.  Thus 
he  speaks  of  the  speculum,  sponge-tents,  peri-uterine  cellulitis, 
medicated  pessaries,  vaginal  injections,  caustics  for  ulcers  of  the 
cervix,  dilatation  of  the  constricted  cervix,  a  sound  for  replacing 
the  uterus,  etc. 

As  I  have  already  stated,  Galen  speaks  of  the  speculum  vaginse 
in  the  second  century;  but  Aetius  still  more  clearly  mentions  it 
and  gives  rules  for  its  introduction,  which  are  copied  almost  ver- 
batim by  Puulns  without  acknowledgment.  The  use  of  sponge- 
tents  he  very  fully  describes,  telling  of  their  mode  of  preparation, 
and  even  advising  that  a  thread  should  be  passed  through  them,  for 
removal,  and  that  a  succession  of  them  should  be  employed  till 
complete  dilatation  is  accomplished.^  The  importance  of  injections, 
the  douche,  hip-baths,  and  application  of  caustics  to  ulcers  of  the 
cervix,  he  also  dwells  upon,  and  advises  the  dilatation  of  a  con- 
stricted cervix  by  means  of  a  tin  tube.  The  variety  >of  vaginal  in- 
jections in  use  among  the  Greeks  was  as  great  as  that  of  to  day. 
As  astringents,  pomegranate  rind,  galls,  jdantain,  rose  oil,  alum, 
sumach,  etc.,  were  employed ;  and  as  emollients,  linseed,  poppies, 
barley,  etc.,  exactly  as  we  use  them  now.  They  relied  to  a  great 
extent  upon  the  use  of  medicated  pessaries  in  the  cure  of  ulcerations 
and  inflammatory  engorgements,  employing  wool  covered  with  wax, 
or  butter  mixed  with  saffron,  verdigris,  litharge,  etc.  Octavius 
Horatianus  even  goes  so  far  as  to  advise  a  mixture  of  arsenic,  quick- 
lime, and  sandarach  in  very  foul  ulcers.  In  addition  to  injections 
and  pessaries,  Aetius  mentions  the  use  of  vapor,  medicated  or  simple, 
conducted  to  the  cervix  by  means  of  a  reed  passed  up  the  vagina. 

The  use  of  a  uterine  sound,  passed  into  the  uterus  and  employed 
as  a  repositor,  is  likewise  alluded  to  by  this  author,  in  a  passage 
where  he  advises  that  displacements  of  the  uterus  should  be  cor- 
rected specillo  et  digito. 


>  Dr.  H.  G.  Wright,  Med.-Chir.  Rev.,  No.  Ixxi. 


OF     GYNECOLOGY.  21 

Paul  of  ^gina,  who  succeeded  Aetius,  alludes  distinctly  to  the 
speculum  as  au  instrument  in  general  use  before  his  tinjc.  "If, 
therefore,"  says  he,  "the  ulceration  be  within  reach,  it  is  detected 
by  the  dioptra;  but  if  deep-seated,  by  the  discharges."  And  again, 
"The  person  using  the  speculum  should  measure  with  a  probe  the 
depth  of  the  woman's  vagina,  lest,  the  tube  of  the  speculum  being 
too  long,  it  should  happen  that  the  uterus  be  pressed  u})0n." 

It  is  curious  to  see  how,  even  in  many  minor  matters,  the  ancients 
anticipated  discoveries  which  our  contemporaries  have  brought 
forward  as  entirely  new.  For  example,  the  air-pessary,  made  so 
popular  in  France  and  other  countries  by  Gariel,  is  described  and 
recommended  by  the  Greeks.  Colombat'  declares  that, " The  ancient 
Greek  physicians  made  use  of  pessaries  like  those  just  mentioned, 
(air-pessaries,)  of  the  form  and  length  of  the  male  organ,  which  is 
the  reason  why  they  are  called  nptantaxwra,  or  priapiform  pessaries." 
Albucasis,  in  1104,  describes  herpes  uterinus;  and  uterine  hemor- 
rhoids are  alluded  to  by  Paulus  ^gineta^  in  this  explicit  manner: 
"Hemorrhoids  form  about  the  mouth  and  neck  of  the  uterus,  which 
will  be  discovered  by  the  speculum."  And  thus  it  is  with  so  many 
other  modern  suggestions,  that  the  student  of  ancient  medical 
literature  is  most  willing  to  admit  the  truth  of  the  proposition, 
formulated  by  Aristotle  over  two  thousand  years  ago,  that  "pro- 
bably all  art  and  all  wisdom  have  often  been  already  fully  explored 
and  again  quite  forgotten." 

The  learning  of  the  Greek  School  was  appropriated  by  the 
Roman,  which  was  an  oft'shoot  from  it,  as  the  writings  of  Celsus, 
Aspasia,  Moschion,  and  Antyllus  abundantly  testify.  But  the 
knowledge  of  the  schools  of  Greece  and  Rome  was  destined  to  be 
scattered  abroad.  At  the  period  of  the  subjugation  of  Egypt  and 
the  destruction  of  the  celebrated  library  at  Alexandria  hy  the 
Saracens,  A.  D.  640,  it  passed  as  a  trophy  of  war  into  the  hands  of 
the  Moslem  invaders.  "In  a  few  centuries  the  fanatics  of  Moham- 
med had  altogether  changed  their  appearance,"  says  the  learned 
Draper.3  "When  the  Arabs  conquered  Egypt,  their  conduct  was 
that  of  bigoted  fanatics;  it  justified  the  accusation  made  by  some 
against  them,  that  they  burned  the  Alexandrian  library  for  the 
purpose  of  heating  the  baths.  But  scarcely  were  they  settled  in 
their  new  dominion,  when  they  exhibited  an  extraordinary  change. 


'  Diseases  of  Females,  Meigs's  translation,  p.  1.52. 
2  Sydenham  Society's  edition,  vol.  i,  p.  645. 
^  Intellectual  Development  of  Europe,  p.  285. 


22  HISTORICAL    SKETCH 

At  once  they  became  lovers  and  zealous  cultivators  of  learning." 
The  physicians  of  Alexandria  were  greeted  by  them  as  instructors, 
and  from  the  seed  thus  planted  sprang  up  the  Arabian  School. 
With  other  information,  of  course,  they  gained  that  pertaining  to 
gynecology,  but,  the  Mohammedan  laws  forbidding  the  examination 
of  women  by  one  of  the  opposite  sex,  the  study  languished  in  their 
hands;  and  although  Rhazes,  Avicenna,  and  their  successors  copied 
from  Greek  writers  upon  it,  a  want  of  zeal,  due  to  want  of  personal 
observation  and  experience,  allowed  a  retrograde  movement  to 
occur  which  left  the  subject  enveloped  in  darkness  for  centuries 
afterwards.  Albucasis,  one  of  the  last  of  this  school,  flourished  at 
the  end  of  the  eleventh  century,  and  after  him,  although  from  time 
to  time  writers  of  greater  or  less  merit  on  diseases  peculiar  to 
women  appeared,  nothing  worthy  of  special  note  occurs,  except  the 
occasional  allusion  to  the  speculum,  which  had  evidently  fallen 
almost  entirely  into  disuse. 

We  have  then  sufiieient  data  to  warrant  the  belief  that  the  phy- 
sicians who  flourished  from  the  foundation  of  the  Greek  School 
of  Medicine,  400  years  before  Christ,  to  the  dispersion  of  the  Alex- 
andrian School  by  the  Saracens,  640  years  after  Christ,  were  well 
informed  in  gynecology,  and  were  familiar  with  means  of  investi- 
gation which  were  subsequently  lost,  or  ceased  to  be  appreciated. 
They  fully  sustain  the  statement  of  the  English  translator  of  the 
works  of  Hippocrates  that,  "They  furnish  the  most  indubitable  proof 
that  the  obstetrical  art  had  been  cultivated  with  most  extraordinary 
ability  at  an  early  period." 

It  must  not,  however,  be  supposed  that  the  knowledge  of  the 
ancients  was  of  the  same  exact  and  scientific  nature  as  that  which 
has  prevailed  since  the  modern  introduction  of  the  speculum.  He 
who  seeks  in  this  literature  for  distinct  and  lucid  pathological  data 
will  surely  meet  with  disappointment.  They  did  not  sufliciently 
separate  inflammations  of  the  puerperal  and  non-pueriteral  uterus, 
confounded  affections  of  that  organ  with  those  of  the  pelvic  areolar 
tissue,  and  made  no  distinctions  between  diseases  of  the  mucous 
membrane  and  parenchyma,  nor  the  morbid  states  of  the  neck  and 
body.  Among  their  remedies  were  numerous  articles  which  to-day 
we  regard  as  inert  or  even  injurious — as  pigeon's  dung,  woman's 
milk,  stag's  marrow,  etc.;  and  Aetius  and  Paulus  seem  to  have 
been  as  partial  to  the  "grease  of  geese"  as  our  Milesian  population 
is  at  present.  To  make  amends  for  this  many  a  valuable  and  sug- 
gestive thought  may  be  gleaned  with  reference  to  diagnosis  and 
treatment.     This  has  certainly  been  proved  by  our  experience  of 


OF    GYNECOLOGY. 


23 


the  past,  and  we  have  no  evidence  to  warrant  the  belief  that  these 
rich  mines  have  yet  been  exhausted. 

The  learning  of  the  Arabians  was  in  time,  like  that  of  the  rest 
of  the  world,  gradually  enshrouded  by  the  ignorance  and  supersti- 
tion of  the  period  termed  the  "  Dark  Ages."  During  that  time 
many  of  their  writings,  as  well  as  those  of  the  Greek  and  lioman 
schools,  were  destroyed  or  lost  ;  but  as  society  emerged  from  the 
darkness  which  overshadowed  its  intelligence,  we  see  the  thread 
at  once  taken  up  and  followed,  though  languidly  and  without  vigor, 
to  the  beginning  of  the  nineteenth  century. 

Toward  the  middle  of  the  seventeenth  century  we  find  very  spe- 
cial and  full  allusion  made  to  the  speculum  and  its  uses  by  Ambrose 
Par^  and  Scultetus  ;  the  instrument  being  well  represented  by  dia- 
grams, with  descriptions  attached. 

Fig.  1. 


Ancient  valvular  specula.     (Scultetus.) 

"  Fig.  1,"  says  Scultetus,  "  is  an  instrument  which  they  call 
'speculum  ani,  vaginae  et  uteri,'  in  that  by  its  help  ulcers  of  the 
rectum,  vagina,  and  uterus  may  be  seen,  to  be  carefully  observed, 
according  to  their  extent  and  kind." 

Aetius  and  Paulus  evidently  knew  of  a  tubular  speculum,  since 
they  say,  "lest  the  tube  of  the  speculum  be  too  long,"  etc.;  but 
Scultetus,  as  already  shown,  figures  a  bi-valve  and  quadri-valve, 
closely  resembling  those  in  our  hands  at  present.  It  is  worthy  of 
mention,  in  this  connection,  that  there  is  now  preserved  in  the 
Museo  Borbonico  at  Naples,  a  bi-valve  speculum  which  was  removed 
from  the  ruins  of  Pompeii. 


24  HISTORICAL    SKETCH 

It  has  already  been  stated  that  Aetius  makes  reference  to  a  sound 
for  replacing  the  uterus.  This  is  by  no  means  the  first  notice  of  this 
useful  instrument,  for  it  is  repeatedly  mentioned  by  Hippocrates. 
One  of  six  passages  from  writings  imputed  to  him,  I  translate  from 
the  recent  work  of  Monsieur  T.  Gallard.^ 

"  Treatment  for  rendering  fertile  a  sterile  woman;  attention  is  directed 
to  that -part  which  consists  in  replacing  a  displaced  neck  of  the  uterus. 

"  Just  after  the  patient  has  taken  a  bath  and  a  fumigation,  open 
the  uterine  mouth  and  replace  it  at  the  same  time,  if  necessary,  with 
a  sound  of  tin  or  lead,  at  first  small  in  size,  then  larger,  if  it  passes, 
until  the  difficulty  seems  remedied ;  dip  the  sound  in  any  emol- 
lient pre[)aration  which  may  be  thought  best,  and  which  should  be 
rendered  liquid  by  melting. "^ 

A  recent  biographer  of  Harvey^  remarks,  "That  the  older  writers 
looked  upon  the  vagina  and  uterus  as  one  organ,  and  wdien  they 
spoke  of  the  former,  they  either  called  it  '  uterus'  or  '  cervix  uteri.' 
What  we  now  call  the  cervix  uteri,  they  called  the  internal  cervix; 
and  as  far  as  my  reading  goes,  no  operative  procedure  upon  this 
part  of  the  womb,  when  in  its  unimpregnated  state,  had  ever  been 
attempted  before  Harvey  invented  his  dilator,  and  used  intra-uterine 
injections  of  sulphate  of  iron." 

If  the  passage  recently  quoted  does  not  carry  conviction  that 
the  manipulations  recommended  have  reference  to  the  neck  of  the 
uterus  and  not  to  the  vagina,  the  following,  from  the  same  source, 
will  do  so. 

'•'■  Treatment*  of  cases  in  which  the  semincd  fluid  is  not  retained  on 
account  of  an  imperfection  in  the  iderine  orifice. 

"In  those  cases  in  which  seminal  fluid  escapes  immediately  after 
intercourse,  the  cause  is  in  the  mouth  of  the  womb.  They  should 
be  treated  thus:  if  the  orifice  is  very  much  contracted  it  should  be 
dilated  with  very  small  bits  of  pine  wood  and  lead."  We  cannot 
suppose  that  in  cases  in  which  intercourse  was  practicable  any  con- 
traction below  the  os  externum  uteri  could  exist,  rendering  such 
dilatation  necessary. 

Professor  Simpson*  asserts  that  among  the  ancients  the  sound  was 
resorted  to  only  for  dilatation  of  the  cervix,  and  not  for  exploration 
and  measurement.     The  specillum  mentioned  by  Aetius  was  em- 

'  LeQons  Cliniques  sur  les  Maladies  des  Femmes,  p.  115. 
2  Hippocrate  ffiuvres  Completes.     Tome  vii,  p.  379. 
^  Obstet.  Journ.  Great  Britain  aud  Ireland,  vol.  1,  p.  26. 
"  Gallard,  op.  cit.,  p.  116. 
*  Obstet.  Works. 


OF    GYNECOLOGY.  25 

ployed  for  reposition,  while  Hippocrates  advises  the  use  of  a  sound 
hollowed  out  on  one  side,  and  covered  by  medicated  ointments: 
this,  "the  operator  introduces  into  the  uterine  orifice,  and  pushes 
onwards  so  as  to  make  it  enter  the  interior  of  the  uterus.  When 
the  medicinal  substance  is  melted,  the  sound  is  withdrawn,"^  In 
1657,  a  probe,  used  as  we  now^  employ  the  uterine  sound,  and  in- 
tended especially  for  uterine  exploration,  was  actually  described 
by  Wierus,^  and  alluded  to  by  Hilken,  Cooke,  and  others. 

As  we  pass  in  review  the  chief  works  w^hich  appeared  upon  our 
subject  in  the  eighteenth  century,  we  find  frequent  mention  of  the 
speculum,  which  is  spoken  of  as  a  matter  of  course  in  the  treatment 
of  uterine  affections,  and  yet  was  evidently  not  so  employed  as  to 
render  it  really  a  valuable  aid  in  diagnosis  or  treatment.  This  con- 
stitutes one  of  the  most  curious  episodes  met  with  in  the  history  of 
any  discovery  with  which  we  were  acquainted.  A  most  simple  and 
useful  instrument  was  not  only  well  known  in  ancient  times,  and 
subsequently  fell  into  disuse,  but  fell  into  disuse  without  having 
ever  been  really  forgotten.  It  was  described  by  successive  writers 
up  to  the  nineteenth  century  in  language  as  distinct  as  words  could 
make  it ;  and  yet  not  only  did  they  who  read,  but  they  who  wrote 
it,  not  comprehend  its  meaning  or  appreciate  its  significance. 
Like  the  Indians  possessed  of  the  diamond,  all  saw  and  yet  none 
valued.  IIow  could  Ambrose  Par^,  for  example,  writing  in  1640, 
have  indicated  its  use  more  clearly  than  when  he  tells  us,  in  chapter 
xix,  that  ulcers  of  the  womb  may  be  recognized,  "  by  the  sight,  or 
hy  putting  in  a  speculum?^'  In  a  copy  of  his  works,  in  the  library 
of  Prof.  W.  A.  Hammond,  the  w^ord  speculum  is  italicized  in  this 
sentence.  Scultetus,  as  we  have  seen,  not  only  described,  but 
figured  the  instrument  in  1683. 

In  1761,  Astruc,  "  Poyal  Prof,  of  Physic  at  Paris,"  in  describing 
occlusion  of  the  vagina  and  obstruction  to  the  menstrual  flow,  says: 
"  There  is  nothing  more  required  than  to  examine  the  vagina  by 
introducing  the  finger  into  it,  rubbed  previously  with  oil  or  poma- 
tum ;  but,  if  that  be  not  sufficient,  a  speculum  uteri  may  be  used,  or 
some  other  more  simple  instrument  for  dilatation,  in  order  to  be 
able,  by  means  of  the  dilatation  of  the  vagina,  to  judge  by  the  sight 
of  what  the  touch  could  not  decide." 

In  1801,  forty  years  after  this,  R^camier  is  supposed  by  many  to 

'  Gallard,  op.  cit,  p.  116. 

*  Dr.  H.  G.  "Wright,  Diseases  of  Women,  Eng.  ed.,  vol.  i,  p.  135. 


26  HISTORICAL    SKETCH 

have  invented  the  speculum.  Most  assuredly  it  was  not  for  the  in- 
vention, but  for  the  regeneration  of  an  instrument  which  had  been 
curiously  lost  sight  of,  that  the  world  was  indebted  to  this  great 
man,  who  was  really  the  ibunder  of  the  modern  school  of  gynecology. 
Guided  by  the  advice  found  in  many  works  which  his  library  must 
have  contained,  works  with  which  to  suppose  him  not  to  have  been 
perfectly  familiar  would  be  to  cast  a  slur  upon  his  medical  research, 
he  emi)loyed  a  speculum  vaginae  in  1801.  Like  his  predecessors,  he 
did  not  appreciate  the  great  results  which  were  to  flow  from  it ;  nor 
does  he  appear  to  have  regarded  himself  as  having  invented  it.  It 
was  not  until  1818,  that  he  introduced  it  to  the  profession,  and  gave 
it  its  place  as  a  valuable  addition  to  science.  Can  any  one  suppose 
that  it  could  have  required  seventeen  years  of  experimentation  and 
study  for  a  man  with  the  talent  of  Recamier,  to  have  applied  this 
simple  and  useful  instrument  to  purposes  of  utility  ?  Is  it  not  more 
likely  that  the  experience  of  seventeen  years  taught  him  the  full 
value  of  the  instrument  ?  The  credit  which  belongs  to  Recamier 
is  not  that  of  an  inventor,  but  that  which  is  equally  great,  of  hav- 
ing recognized  the  value  of  what  was  well  known,  but  not  appre- 
ciated by  his  predecessors  and  contemporaries. 

Even  before  this  fortunate  revival,  as  the  eighteenth  century 
approached  its  close,  the  glimmer  of  the.  new  era  which  was  about 
to  dawn  could  clearly  be  detected  in  the  advanced  views  which  were 
promulgated  by  Garangeot  and  Astruc  in  France,  and  Deiniian, 
John  Clark,  and  Hamilton  in  England.  The  early  part  of  the 
nineteenth  century  found  the  field  occupied  chiefly  by  Sir  Charles 
Clarke  and  Dr.  Gooch  in  England,  and  Recamier  and  Lisfranc  in 
France.  These  were  not  the  only  eminent  writers  of  that  time, 
but  they  were  unquestionably  those  who  chiefly  moulded  profes- 
sional opinion. 

Even  at  that  period  gynecologists  ranged  themselves  into  two 
parties,  which,  so  late  as  at  our  day,  have  scarcely  coalesced.  In 
England  the  feeling  was  strongly  in  favor  of  regarding  the  local 
disorder  as  the  result  and  not  the  cause  of  concomitant  constitu- 
tional derangement;  while  in  France  the  uterine  disease  was  viewed 
as  the  main  element,  and  the  general  condition  as  dependent  upon 
and  resulting  from  it. 

The  great  advantages  of  the  speculum  secured  its  rapid  adoption 
in  France.  More  slowly  it  forced  its  way,  in  spite  of  many  preju- 
dices, into  Great  Britain,  and  before  a  great  many  years  had  passed, 
it  was,  throughout  the  civilized  world,  placed  upon  an  enduring 


OF    GYNECOLOGY.  27 

basis  as  one  of  the  many  boons  bestowed  by  medicine  upon 
humanity.  The  way  being  opened  for  investigation  by  this  instru- 
ment, new  aids  to  diagnosis  and  treatment  were  rapidly  brought 
forward.  In  1826,  Guilbert  read  before  the  Academy  of  Medicine 
of  Paris  an  essay  proposing  the  application  of  leeches  to  the  cervix. 
In  1828,  Samuel  Lair  read  before  the  same  body  a  paper  in  which 
he  counselled  the  use  of  the  uterine  sound.  In  1832,  M.  Melier 
presented  an  essay,  in  which  he  ottered  two  new  suggestions  in 
the  treatment  of  uterine  diseases — one,  injections  into  the  cavity 
of  the  cervix;  the  other,  local  applications  through  the  vagina  by 
dossils  of  lint  saturated  with  astringents,  narcotics,  etc.  His  views 
are  quoted  extensively  by  French  writers,  and  l^onat  says  that  the 
author  recognizes,  "avec  une  franchise  qui  I'honore,"  that  Boyle, 
Chaussier,  Guillou,  and  others  had  a  short  time  before  him  used 
similar  means.  Very  curiously  neither  Melier  nor  his  commen- 
tators mention  that  both  these  suggestions  are  made  and  fully 
elaborated  by  Astruc,  in  his  excellent  article  upon  "Ulcers  of  the 
Uterus."  He  describes  these  applications  of  medicated  charpie 
very  carefully,  remarking  that  it  is  advisable  to  "tie  a  thread  to 
every  pledget,  in  order  to  draw  it  out  again  when  it  is  proper  to 
renew  the  dressing."  And  he  not  only  advises  injections  of  water, 
impregnated  with  different,  substances,  into  the  cavity  of  the  womb, 
but  also  the  juices  of  plantain,  houseleek,  nightshade,  etc.  "For," 
says  he,  "as  it  is  of  consequence  that  these  injections  should  enter 
into  the  uterus,  where  the  ulcer  has  its  seat,  it  is  proper  they 
should  be  made  by  a  professor  of  midwifery,  capable  of  introducing 
skilfully  the  end  of  the  canula  into  the  oriiice  of  the  uterus,"  etc. 

At  this  time  arose  the  question  as  to  cancer  of  the  uterus, 
whether  it  was  the  local  manifestation  of  a  general  blood  state,  or 
the  result  of  an  inflammatory  engorgement  long  neglected;  a  ques- 
tion which  excited  warm  discussions,  and  brought  forth  the  most 
opposite  views. 

The  ambition  of  Edcamier  was  not  satisfied  with  exposing  the 
cervix  uteri  to  view.  He  had  the  boldness  to  explore  the  cavity 
of  the  body  of  the  organ,  almost  establishing  the  use  of  the  sound, 
and  even,  by  means  of  a  species  of  scoop  called  a  curette,  ventured 
in  certain  cases  to  scrape  its  investing  mucous  membrane.  In 
addition  he  described,  through  one  of  his  students,  pelvic  cellulitis, 
and  gave  tlie  first  intimation  which  modern  observers  have  had  of 
the  possibility  of  pelvic  hematocele. 

The  improvements  inaugurated   by  Recamier  mark  an   era   iu 


28  HISTORICAL    SKETCH 

gynecology ;  one  scarcely  less  im[)ortant  was  created  by  the  ap- 
pearance in  the  field  of  labor  of  the  late  Sir  James  Simpson,  of 
Edinburgh.  About  the  year  1843,  he  rapidly  developed  and  recom- 
mended to  tlie  profession  several  of  the  most  important  means  of 
diagnosis  now  at  our  command.  The  utilization  of  the  uterine 
sound,  whicih  Lair  had  never  succeeded  in  introducing  into  general 
l)ractice,  and  the  dilation  of  the  canal  of  the  cervix  by  s|:>onge-tents, 
so  that  the  body  of  tlie  uterus  may  be  examined,  are  both  due  to  his 
o-onius  and  enterprise.  He  likewise  contributed  from  time  to  time 
original  and  valuable  papers  upon  pelvic  cellulitis,  hematocele,  ute- 
rine flexions,  etc.  His  articles,  indeed,  first  excited  the  study  of  ute- 
rine displacements  in  Great  Britain,  and  to  his  eiforts  may  be  traced, 
in  a  great  degree,  the  interest  which  has  been  of  late  years  aroused  in 
that  country  with  reference  to  uterine  pathology.  Until  this  time 
the  subject  had  attracted  very  little  attention  there,  and  advances 
which  had  been  made  in  it  were  due  almost  entirely  to  French 
pathologists.  It  is  true  that  the  excellent  work  of  Sir  Charles 
Clarke  existed;  but  that  warm  and  zealous  interest  which  has  since 
resulted  in  so  much  benefit  to  gynecology,  had  not  then  been  excited. 
But  Prof.  Simpson  wms  not  alone  in  this  work.  Dr.  J.  H.  Bennet, 
of  London,  at  that  time  a  young  physician,  who  had  for  some  years 
served  as  interne  in  the  hospitals  of  Paris,  returned  to  his  own 
country  imbued  with  the  views  which  Recamier  and  Lisfranc  had 
disseminated  among  a  large  circle  of  followers.  In  1845,  the  first 
edition  of  his  work  on  Inflammation  of  the  Uterus  appeared,  and 
it  is  safe  to  assert  that  no  work  of  modern  times,  written  upon  any 
subject  connected  with  our  profession,  has  exerted  a  more  decided 
and  profound  influence.  Taking  up  the  matter  with  a  vigor  and 
energy  which  forced  attention,  if  not  conviction,  he  produced  an 
undeniable  impression  upon  the  profession,  not  only  in  his  own 
country,  but  in  Germany,  France,  and  America.  However  others 
may  differ  from  him,  no  candid  mind  can  deny  him  the  obligation 
under  which  lie  has  place<l  his  brethren  by  arousing  their  attention 
and  directing  their  investigations  into  proper  channels.  The  chief 
points  insisted  upon  in  his  work  are  these:  1.  That  inflammation 
is  the  chief  factor  in  uterine  affections,  and  that  from  it  follow, 
as  results,  displacements,  ulcerations,  and  affections  of  the  appen- 
dages. 2.  That  menstrual  troubles  and  leucorrhoea  are  merely 
symptoms  of  this  morbid  state.  3.  That  in  the  vast  majority  of 
cases,  inflammatory  action  will  be  found  to  confine  itself  to  the 
cervical  canal,  and  not  to  affect  the  cavity  of  the  body.  4.  The 
propriety  of  attacking  the  disease  in  its  habitat  by  strong  caustics. 


OF    GYNECOLOGY.  29 

It  is  now  twenty-six  years  since  the  appearance  of  the  first 
edition  of  Dr.  Beiniet's  work,  and  since  during  that  period  his 
views  have  been  freely  criticized  and  vehemently  opposed,  since  too 
his  own  ex}ierience  has  rii-ened  and  he  has  had  abundant  time  for 
moi-e  mature  reflection,  it  must  be  a  matter  of  great  interest  to  all 
to  know  to  what  extent  his  opinions  have  been  modified.  In  the 
London  Lancet  appears  the  abstract  of  a  })aper  read  by  him  before 
the  British  Medical  Association  in  1870,  which  serves  to  contrast 
his  present  with  his  former  views. 

The  purport  of  this  paper  will  be  best  given  in  the  recapitulation 
by  which  the  author  concludes  it: — 

"  1.  I  consider  that,  under  the  influence  of  mechanical  doctrines  pushed 
to  an  extreme,  uterine  displacements  are  by  many  too  much  studied />er  se, 
independentl3'  of  the  inflammatory  lesions  tliat  comphcate  and  often 
occasion  them.  2.  That  the  examinations  made  to  ascertain  the  existence 
of  inflammatory^  complications  are  often  not  made  with  sufficient  care  and 
minuteness,  as  evidenced  by  the  fact  that  I  constantly  see  in  practice 
cases  in  which  inflammatory  lesions  have  been  entirely  neglected,  and  the 
secondary  displacements  alone  treated.  3.  That  inflammatory  lesions 
are  often  the  principal  cause  of  the  uterine  displacements  through  the 
enlargement  and  increased  weight  of  the  uterus,  or  of  a  portion  of  its 
tissues,  which  they  occasion.  4.  That  when  such  inflammatory  conditions 
exist,  as  a  rule  they  should  he  treated  and  cured,  and  then  time  given  to 
nature  to  absorb  morbid  enlargements  betbre  mechanical  means  of  treat- 
ment are  resorted  to." 

Soon  after  the  apjiearance  of  Dr.  Bennet's  work  a  discussion 
sprang  up  between  its  author  on  one  side,  and  Drs.  Robert  Lee, 
West,  and  Tyler  Smith  on  the  other,  M'ith  reference  to  the  true 
character  of  ulceration  of  the  r.eck  ;  Dr.  Bennet  supporting  the 
view  that  the  cervix  is  often  affected  by  inflammatory  ulceration, 
and  his  opponents  denying  it.  The  importance  which  he  attached 
to  the  matter  may  be  appreciated  from  the  following  quotation. 
In  reviewing  the  state  of  uterine  pathology  in  Great  Britain,  as 
illustrated  by  the  standard  work  of  Sir  Charles  Clarke,  he  says: 
"Various  forms  of  cancerous  ulceration  are  carefully  described,  but 
the  very  existence  of  inflammatory  ulceration  is  not  mentioned. 
:N'ow  when  we  reflect  that,  as  I  shall  hereafter  show,  in  nearly  five 
cases  out  of  six  of  confirmed  uterine  disease,  in  which  chronic  dis- 
charges, mucous,  puriform,  or  sanguinolent,  or  other  well-marked 
uterine  symptoms  are  jn-esent,  there  exists  inflammation  or  inflam- 
matory ulceration  of  the  cervix,  it  is  easy  to  conceive  how  erroneous 


30  HISTORICAL    SKETCH 

must  be  the  views  respecting  uterine  patliology,of  a  medical  school 
ignorant  of  so  vitally  important  a  circumstance." 
"  The  last  edition  of  Dr.  Bennet's  work  was  published  in  1861,  and 
a  quotation  of  the  views  held  by  him  in  1870,  shows  that  they 
are  essentif.lly  unaltered.  Yet  I  believe  that  I  am  correct  in  saying 
that  the  great  majority  of  the  progressive  gynecologists  of  our 
time  sustain  the  views  which  are  opposed  to  his.  I  find  myself 
to-day  endorsing  the  action  of  Sir  Charles  Clarke  in  publishing  a 
work  on  diseases  of  women  "in  which  the  very  existence  of  inflam- 
matory ulceration  is  not  mentioned,"  or  is  mentioned  only  for  the 
purpose  of  disputing  its  validity. 

One  great  advance  which  was  effected  by  the  work  of  Dr.  Bennet 
was  the  placing  upon  a  surer  basis  than  it  had  yet  occupied,  the 
differentiation  of  engorgement  and  induration  from  commencing 
cancer  of  the  neck. 

It  would  be  Avell,  before  proceeding  farther,  to  consider  very 
Driefly  the  different  pathological  views  which  from  this  time,  and 
even  somewhat  before  it,  were  offered  to  the  profession,  and  more 
or  less  generally  adopted. 

They  may  be  thus  enumerated  : — 

1st.  That  inflammation  is  the  starting-point  of  most  of  the  affec- 
tions of  the  uterus,  and  that  a  large  number  of  evils  follow  this 
morbid  state  as  results. 

2d.  That  uterine  disorder  is  dependent  upon  a  constitutional 
derangement,  and  would  yield  without  other  treatment  than  that 
directed  to  the  removal  of  the  general  condition. 

3d,  The  view  of  Dr.  Bennet,  which  is  similar  to  the  first  men- 
tioned, with  this  additional  point,  that  metritis  generally  limits 
itself  to  the  neck,  and  only  exceptionally  affects  the  body. 

4th.  The  view  of  Dr.  Tyler  Smith,  that  leucorrhoea  arising  from 
glandular  inflammation  in  the  cervix  is  the  cause  of  granular  de- 
generation  of  this  part,  and  of  subsequent  engorgement. 

5th.  The  view  that  uterine  disorders  often,  if  not  generally,  com- 
mence in  displacement,  which  is  a  primary  and  not  a  secondary 
condition,  and  that  to  relieve  the  train  of  morbid  symptoms,  this, 
its  exciting  cause,  should  be  first  removed. 

6th.  The  view  that  uterine  disorder  is  commonly  the  result  of 
ovarian  inflanmiation,  which  reacting  on  the  womb  is  the  prime 
mover,  in  many  cases,  of  its  morbid  states. 

I  have  no  intention  of  fully  discussing  here  the  merits  of  these 
theories,  but  will  limit  myself  to  a  tbw  words  connected  with 
each. 


OF    GYNECOLOGY.  31 

The  theory  mentioned  first  in  this  enumeration  is  the  oldest  on 
record,  the  writers  of  the  Greek  School,  even,  adopting  it.  Thus 
Paulus  JEgineta  heads  his  chapter  on  the  subject, "  Inflammation 
of  the  uterus  and  change  of  its  position."  One  of  the  symptoms 
of  such  inflammation  he  considers  to  be  retroversion  of  the  uterus. 
In  the  beginning  of  the  present  century  this  was  generally  accepted 
in  France.  Lisfranc  and  Eecamier  adopted  it,  and  it  was  trans- 
ferred to,  and  advocated  in,  Great  Britain  by  the  writings  of  Dr. 
Bennet. 

The  views  of  this  last  author,  appearing  as  they  did  at  a  time 
when  the  field  of  uterine  pathology  .was  almost  entirely  uncultivated, 
and  characterized  as  they  were  by  a  great  deal  of  persuasive  force, 
produced  in  this  country  a  marked  impression.  As  to  myself  I  am 
forced  freely  to  confess  that  since  the  publication  of  the  first  edition 
of  this  work  my  opinions  with  regard  to  them  have  undergone  a 
material  alteration.  This  alteration  has  resulted  not  from  theoreti- 
cal reasoning,  but  from  careful  and  candid  investigation  and  experi- 
mentation at  the  bedside.  I  have  come  to  regard  the  belief  of  Dr. 
Bennet  in  inflammation  as  the  great  moving  cause,  the  common 
factor,  in  the  production  of  uterine  diseases,  as  an  error.  And  as 
my  views  have  thus  altered  with  reference  to  pathology,  they 
have,  necessarily,  likewise  changed  with  reference  to  treatment. 
It  appears  to  me  that  the  time  has  arrived  when  many  who  form- 
erly accepted  the  opinions  of  Dr.  Bennet  will  be  pre[)ared  to  admit 
the  fact  that  liis  treatment  is  too  severe ;  his  use  of  caustics  too 
heroic  ;  and  his  neglect  of  artificial  support  to  the  displaced  uterus 
too  decided.  'No  one  could  have  accepted  his  views  more  cor- 
dially than  I  did.  They  were  seductive  by  reason  of  their  sim- 
plicity, and  plausible  from  their  apparent  rationality.  Careful  ob- 
servation at  the  bedside  in  as  large  a  field  as  could  be  desired,  has 
led  me  to  feel  that  evil,  rather  than  good,  results  from  an  adherence 
to  them.  Feeling  this,  I  shall  strive  in  the  work  which  I  am  now 
undertaking  so  to  modify  my  statements  as  to  meet  what  I  regard 
as  the  true  requirements  of  the  subject. 

No  one  can  devote  himself  to  the  practical  study  of  uterine 
diseases  without  being  impressed  with  the  strong  grounds  which 
exist  for  the  maintenance  of  the  second  of  the  theories  mentioned. 
No  grave  uterine  trouble  affects  the  system  for  any  length  of  time 
without  reacting  to  a  greater  or  less  extent  upon  the  general  health. 
The  nervous  system  becomes  greatly  disordered,  the  functions  under 
its  influence  are  badly  performed,  and  derangement  in  hematosis 


I 


32  HISTORICAL    SKETCH 


is  the  invariable  result.  As  the  local  disease  often  approaches 
stealthily,  and  may  exist  for  a  length  of  time  without  exciting 
suspicion,  what  is  more  natural  than  that  many  should  view  it  as 
one  of  the  numerous  results  of  the  genei-al  depreciation  ?  These 
three  facts,  liowever,  which  will  constantly  repeat  themselves,  as 
often,  I  may  say,  as  favorable  cases  offer  for  testing  the  question, 
will,  I  think,  very  generally  lead  to  a  distrust  of  the  doctrine:  1st, 
the  fact  that  uterine  disease  and  constitutional  derangement  exist- 
ing tOiz;ether,  a  cure  can  rarely  be  effected  by  general  means  alone; 
2d,  that  the  uterine  affection  being  removed,  the  general  state  is  at 
once  improved ;  and,  3d,  that  those  general  conditions  which  pros- 
trate the  vital  forces  to  the  last  degree,  as,  for  instance,  tuberculosis, 
ursemia,  scurvy,  leucocythaemia,  etc.,  destroy  life  without  ever 
showing,  unless  as  an  exception  to  a  rule,  uterine  disease  as  a  con- 
sequence. 

The  constitutional  depreciation  of  a  woman  will,  however,  some- 
times prove  a  predisposing  cause  of  local  disease.  As  granular 
degeneration  under  the  eyelids  will  arise  from  this  cause,  so  will  a 
kindred  condition  often  occur  on  the  cervix  uteri,  yet  both  will 
require  local  as  well  as  general  treatment.  The  enfeebled  woman 
is  more  liable  to  subinvolution,  passive  congestion,  and  displace- 
ments, after  delivery,  than  the  strong ;  and  inflammation  of  the 
glands  of  the  cervix  is  a  well-known  result  of  phthisis  pulmonalis, 
tertiary  syphilis,  and  anemia. 

The  theory  of  Dr.  Tyler  Smith^  I  lay  before  the  reader  in  his 
own  words:  "It  is  my  conviction,  notwithstanding,  that  in  the 
majority  of  cases  in  M'hich  morbid  states  of  the  os  and  cervix  are 
present,  cervical  leucorrhoea,  or,  in  other  words,  a  morbidly  aug- 
mented secretion  from  the  mucous  glands  of  the  cervical  canal,  is 
the  most  essential  part  of  the  disorder,  and  that  the  diseased  con- 
ditions of  the  lower  segment  of  the  uterus,  which  have  been  made 
so  prominent,  are  often  secondary  affections  resulting  from  the 
leucorrhoeal  malady."  This  theory  was  by  no  means  a  new  one 
when  advanced  as  above  mentioned,  for  Lisfranc^  mentions  it  thus: 
"Observation  proves  that  leucorrhoea  can  in  the  first  place  cause 
uterine  engorgements,  and  that  later  it  may  be  kept  up  by  them ; 
it  occasions  them  often." 

Lisfranc,  however,  says  "often,"  while  Dr.  Smith  says,  "in  the 
majority  of  cases."     But  even  before  Lisfranc  it  had  attracted 


On  Leucorrhoea.  2  Clin.  Chirurg.,  vol.  ii,  p.  303. 


OF    GYNECOLOGY.  33 

attention,  for  Piiulus  ^gineta'  gives  "defluxion"  as  one  of  the 
causes  of  "  ulceration  of  the  womb."  That  an  acrid  leucorrhoeal 
discharge  will  create  abrasion  of  the  os,  follicular  vaginitis,  ure- 
thritis, pudendal  inflammation,  and  pruritus,  no  one  will  deny. 
We  see  a  similar  irritation  occurring  on  the  upper  lip  in  nasal 
catarrh  in  children,  which  sometimes  spreads  as  an  eruption  over  the 
whole  face.  The  leucorrhoea  regarded  by  Dr.  Smith  as  the  primary 
disease  is,  however,  only  a  symj^tom  of  cervical  endometritis,  which 
may  disorder  nutrition  in  the  deep  tissues  of  the  cervix,  and  result 
in  enlargement  and  induration.  The  views  of  Dr.  Smith  were 
brought  forth  at  a  time  when  Dr.  Bennet  was  pressing  the  theory 
of  inflammation  as  the  keystone  of  uterine  pathology,  and  in  com- 
bating the  idea  of  parenchymatous  inflammation,  he  recorded  the 
important  fact  that  the  morbid  state  described  under  that  name  is 
very  often  preceded  by,  and  results  from  disease  taking  its  rise  in 
the  mucous  lining  of  the  canal.  Dr.  Smith's  position  was  main- 
tained with  all  that  ability  and  force  which  have  rendered  him  so 
popular  as  an  author  amongst  us  in  America,  and  the  influence  of 
his  writings  upon  uterine  pathology  can  be,  at  present,  clearly 
traced  in  this  country. 

In  the  year  1854,  a  discussion,  which  soon  assumed  extensive 
proportions  and  elicited  great  warmth,  arose  in  the  Academy  of 
Medicine  of  Paris,  with  reference  to  the  treatment  of  uterine  dis- 
placements. M.  Velpeau  stood  forth  as  champion  of  the  view 
which  is  here  expressed  in  his  own  words.  "  I  declare,  nevertheless, 
that  the  majority  of  the  women  treated  for  other  atfcctions  of  the 
uterus  have  onl}^  displacements,  and  I  affirm  that  eighteen  times 
out  of  twenty,  patients  suftering  from  disease  of  the  womb,  or  of 
some  other  part  of  this  region,  those  for  instance  in  whom  they 
diagnose  inflammation  (engorgements),  are  afl:ected  by  displace- 
ments." In  this  and  subsequent  discussions  he  was  upheld  by  some 
of  the  most  eminent  practitioners  of  Paris,  and  by  many  the  view 
then  expressed  is  still  adhered  to.  No  one  of  experience  will  ques- 
tion the  fact  that  a  disorder  of  position  of  the  uterus  will  often 
result  in  subsequent  disorder  in  nutrition  and  sensibility.  Everv 
one  must  have  repeatedly  met  with  cases  in  which  the  reposition 
and  support  of  a  displaced  uterus  have  atonce  dissipated  a  collection 
of  sym[itoms  which  by  many  would  have  been  attributed  to  inflam- 
mation of  the  mucous  lining  or  parenchyma.     Every  one  must  have 

1  Op.  cit.,  p.  624 


34  HISTORICAL    SKETCH 

found  in  many  cases  the  relief  of  a  disi)lacement,  wliich  was  re- 
garded as  only  an  unimportant  concomitant  of  the  morbid  state, 
result  in  complete  cure.  But  admitting  this  is  merely  admitting 
the  propriety  of  regarding  displacement  as  one  of  many  untoward 
influences  which  may  disorder  the  innervation,  circulation,  and 
nutrition  of  the  uterus;  not  making  it  the  chief  factor  in  the  pro- 
duction of  uterine  diseases. 

The  primary  importance  of  displacement  was  long  ably  main- 
tained in  this  country  by  the  late  Prof.  Hugh  L.  Hodge  of 
Philadelphia,  and  the  adherents  of  this  theory  are  numerous. 

The  most  signal  instance  of  its  adoption  which  has  recently 
occurred  is  that  of  Dr.  Graily  Hewitt,  of  London.  While  he 
does  not  make  displacement  absolutely  essential  as  a  primary 
factor  of  uterine  disease,  and  limits  his  belief  in  its  agency  almost 
entirely  to  flexions  or  deformities  of  shape,  the  importance  which 
he  attaches  to  such  displacements  may  be  gathered  from  the  follow- 
ing quotations  from  the  third  edition  of  his  valuable  work  upon  the 
diseases  of  women. 

"  a.  Patients  suffering  from  symptoms  of  uterine  inflammation 
(or,  more  properly,  from  symptoms  referal/ie  to  the  uterus)  are 
almost  universally  found  to  be  affected  with  flexion  or  alterations 
in  the  shape  of  the  uterus  of  easily  recognized  character,  but  vary- 
ing in  degree. 

"  b.  The  change  in  the  form  and  shape  of  the  uterus  is  freqnentlj^ 
brought  about  in  consequence  of  the  tissues  of  the  uterus  being  pre- 
viously in  a  state  of  unusual  softness,  or  what  may  be  often  correctly 
designated  as  chronic  inflammation. 

"c.  The  flexion  once  produced  is  not  only  liable  to  perpetuate 
itself,  so  to  speak,  but  continues  to  act  incessantly  as  the  cause  of 
the  chronic  inflammation  present." 

In  a  certain  number  of  cases  very  grave  and  annoying  symptoms 
of  uterine  disease  will  be  found  due  to  chronic  ovaritis,  an  affection 
in  which  treatment  is  so  inefficient  that  every  practitioner  must 
dread  to  meet  it.  The  symptoms  of  uterine  disease  being  present, 
an  exploration  of  the  pelvic  organs  is  made.  lN"o  uterine  disease  or 
any  kind  is  found  to  exist,  but  prolapsed  into  Douglas's  cul  de  sac 
are  found  the  ovaries,  large,  tender,  and  tumefied.  In  other  cases 
uterine  disease  will  be  found  coexistent  with  enlargement,  tender- 
ness, and  displacement  of  the  ovaries,  and  the  practitioner  indulges 
the  hope  that  so  soon  as  the  uterine  disorder  shall  be  cured  the 
ovarian  trouble  will  disappear.  Such  a  sequence,  however,  does  not 
occur,  and   he  recognizes,  to   his   disappointment,  that  what  he 


OF    GYNECOLOGY.  35 

regarded  as  a  secondary  matter  is  really  one  of  primary  importance. 
For  this  reason  no  examination  of  the  uterus  should  be  considered 
complete  which  does  not  involve  a  careful  investigation  of  the  state 
of  the  ovaries. 

For  many  years  a  thorough  sceptic  as  to  the  frequency  of  ovarian 
disorder  as  a  cause  of  the  ordinary  symptoms  of  uterine  disease,  I 
am  now  convinced  of  its  truth,  and  in  few  cases  do  I  give  more 
guarded  prognoses  than  in  those  in  which  I  find  one  or  both  ovaries 
enlarged,  tender,  and  prolapsed. 

Since  the  year  1850,  when  he  published  his  well  known  work  upon 
the  subject  of  Ovarian  Inflammation,  no  one  has  been  a  more  con- 
stant or  consistent  advocate  of  the  claims  of  ovarian  pathology  upon 
the  notice  of  the  gynecologist  than  Dr.  Tilt,  of  London.  At  a 
meeting  of  the  London  Obstetrical  Society,  in  April  of  the  present 
year,  he  recapitulated  his  views,  and  it  cannot  fail  to  be  a  matter 
of  interest  to  see  how  time  and  experience  have  affected  them.  The 
positions  which  he  originally  took  were  these:  1st.  That  the 
recognized  frequency  of  inflammatory  lesions  in  the  ovaries  and  in 
the  tissues  that  surround  them  is  of  much  greater  practical  import- 
ance tban  is  generally  admitted.  2d.  That  of  all  inflammatory 
lesions  of  the  ovary  those  involving  destruction  to  the  whole  organ 
are  very  rare,  whilst  the  most  numerous,  and,  therefore,  the  most 
important,  may  be  ascribed  to  a  disease  that  may  be  called  either 
chronic  or  subacute  ovaritis.  3d.  That,  as  a  rule,  pelvic  diseases  of 
women  radiate  from  morbid  ovulation.  4th.  That  morbid  ovulation 
is  a  most  frequent  cause  of  ovaritis.  5th.  That  ovaritis  frequently 
causes  pelvic  peritonitis.  6th.  That  blood  is  frequently  poured  out 
from  tlie  ovary  and  the  oviducts  into  the  peritoneum.  7th.  That 
subacute  ovaritis  not  unfrequently  causes  and  ];»rolongs  metritis. 
8th.  .That  ovaritis  generally  leads  to  considerable  and  varied  dis- 
turbance of  menstruation.  9th.  That  some  chronic  ovarian  tumors 
may  be  considered  as  aberrations  from  the  normal  structure  of  the 
Graafiian  cells. 

Dr.  Tilt  pointed  out  that  although  these  views,  when  promul- 
gated, had  been  adversely  criticized  by Drs.  E,igby,"W"est,  Bennet,  and 
Churchill,  they  were  now  to  a  great  extent  accepted,  and  that  they 
have  been  amply  demonstrated  both  clinically  and  necroscopically 
by  Aran,  Bernutz,  Gallard,  Negrier,  and  Lireday.  I  would  emphati- 
cally dissent  from  his  3d  postulate,  which  I  regard  as  entirely  too 
sweeping  an  assertion,  but  with  the  remaining  eight  I  fully  agree. 

Of  late  years  rapid  advances  have  been  made  in  the  suro-ical 
treatment  of  the  diseases  of  women.     Under  the  lead  of  Simpson, 


3(3  HISTORICAL    SKETCH 

Wells,  Brown,  and  Clay,  in  Great  Britain;   of  Simon,  Esmarch, 
Ulrich,  Ilegar,  and  Spiegelberg,  in  Germany;  and  of  Sims,  Atlee, 
Emmet,  Bozeman,  Peaslee,  Dunlap,  Agnew,  and  Kimball,  in  the 
United  States ;  operations  for  ovariotomy,  the  cure  of  ruptured 
perineum,  vesico-vaginal  iistulre,  constriction,  or  tortuosity  of  the 
cervix,  prolapsus  uteri,  etc.,  have  been  perfected  and  are  now  con- 
stantly practised.     For  a  very  long  time  these  valuable  procedures 
were  so  entirely  neglected,  that  professional  o[>inion  in  their  favor 
has  of  late  years,  like  a  pendulum  swung  too  far  in  one  direction, 
gone  to  an  extreme  in  the  other.    The  excessive  surgical  tendency 
of  many  of  the  leading  gynecologists  of  our  day  is  a  matter  to  be 
dejtlored  by  all  who  wish  well  to  gynecology.     Many  conditions 
which  time  and  patient  medical  treatment  would  readily  cure  are 
met   boldly,  and  without  sufficient   consideration,  by   operations 
more  or  less  formidable.     Every  practitioner  must  often  have  seen 
cases  in  wdiich  pelvic  peritonitis  or  cellulitis  has  arisen  from  an 
incision  of  the  neck  of  the  uterus,  or  some  similar  procedure,  in 
which  the  patient  is  for  months  confined  to  bed,  and  in  which  he 
is  forced  to  doubt  the  necessity  for  the  surgical  resource  which  has 
been  productive  of  the  evil.     "No  one  who  reads  these  pages  will 
suspect  me  of  a  want  of  appreciation  of  the  operations  to  .which  I 
have  alluded,  nor  of  timidity  in  employing  them.     I  regard  them 
as  great  advances  in  gynecology,  and  in  practice  commonly  resort 
to  them.     It  is  not  to  their  use,  but  to  their  unquestionable  abuse, 
that  I  am  objecting.     The  last  remark  applies  with  equal  force  to 
the  almost  exclusive  reliance  which  by  many  seems  placed  upon 
local  treatment  in  the  cure  of  uterine  disorders.      One  who  fre- 
quently sees  cases  of  uterine  disease  in  consultation,  wnll  meet  with 
many  in  which  he  is  called  upon  to  urge  cessation  of  all  local  treat- 
ment, as  the  first  step  in  the  proper  management  of  the  case. 

Both  the  science  and  art  of  gynecology  have  been  greatly  advanced 
by  the  pathological  researches  of  the  German  school.  To-day  con- 
fessedly in  advance  of  all  other  nations  in  the  study  of  pathology, 
the  laborious,  conscientious,  and  per.-^evering  scholars  of  that  country 
are  altering  and  improving  our  views  in  reference  to  this  sul)ject, 
while  contributions  of  great  practical  value  are  coming  forth  from 
them  to  enrich  our  literature.  Among  these  may  be  especially  men- 
tioned those  by  Kiwisch,  Lurnpe,  Oppolzer,  Hennig,  Waldeyer, 
Braun,Simon,8piegelberg,and  Martin.  The  work  of  Scanzoni,  trans- 
lated by  Dr.  Gardner,  of  this  city,  is  well  known  to  all,  and  Dr.  John 
Clay,  of  Birmingham,  has  rendered  service  by  his  able  translation 


OF    GYNECOLOGY.  37 

of  the  chapters  of  Kiwisch's  work  on  the  Pathology  and  Treatment 
of  the  Diseases  of  Women  which  relate  to  affections  of  the  ovaries. 

The  first  volume  of  Professor  Julius  M.  Klob,  of  Vienna,  upon 
the  Pathological  Anatomy  of  the  Female  Sexual  Organs,  which 
has  been  translated  by  Drs.  Kammerer  and  Dawson,  of  New  York, 
has  proved  so  valuable  an  addition  to  the  library  of  every  practi- 
tioner in  this  department  that  all  look  with  eagerness  for  the 
appearance  of  the  second,  which  is  now  promised.^ 

It  is  a  great  source  of  pleasure  to  me  before  closing  this  sketch 
to  be  able  to  record  the  fact  that  America  has  not  been  wanting 
in  her  contribution  towards  the  progress  of  this  branch  of  medicine. 
While  the  interests  of  gynecology  were,  during  the  early  part  of 
the  present  century,  advanced  in  other  lands  by  those  whose  names 
have  been  mentioned,  in  America  they  were  pressed  upon  the  atten- 
tion of  the  profession  and  assiduously  cultivated  by  three  able 
advocates,  all,  singular  to  relate,  from  the  same  city — Dewees, 
Meigs,  and  Hodge.  Each  of  these  observers  brought  to  his  work 
the  most  signal  ability  and  enthusiasm,  and  having  abundant  oppor- 
tunities as  public  teachers  and  writers,  of  disseminating  their  views, 
they  each  exerted  a  decided  influence  upon  the  mind  of  the  profes- 
sion. To  the  last  of  these  gentlemen  the  profession  throughout  the 
world  is  more  deeply  indebted  for  means  of  properly  sustaining  the 
uterus  by  pessaries  than  to  any  one  who  has  ever  labored  in  this 
lield,  and  we  see  in  our  day  his  determined  opposition  to  the  phlo- 
gistic theory  of  uterine  disorders  rapidly  gaining  advocates  amongst 
the  ablest  and  most  philosophical  in  our  ranks. 

From  this  country  have  emanated,  as  contributions  to  this  im- 
portant department  of  medicine,  anaesthesia,  ovariotomy,  the  re- 
vival of  the  method  by  which  vaginal  fistulse  have  been  made 
amenable  to  systematic  treatment,  and  which  since  the  time  of 
Gossett  had  been  entirely  forgotten;  and  last,  but  by  no  means  least, 
the  introduction  into  ordinary  practice  of  Sims's  methods  of  explor- 
ing the  pelvic  viscera. 

I  have  elsewhere  called  the  results  of  the  labors  of  Recamier  and 
Simpson  eras  in  the  progress  of  this  department.  I  now  venture 
so  to  style  those  of  Marion  Sims.  In  doing  this  I  make  no  refer- 
ence to  the  improvements  inaugurated  by  him  in  the  treatment  of 
injuries  to  the  genital  organs;  my  allusion  is  to  the  great  advan- 
tages which  now  flow  and  are  to  flow  from  the  invention  of  his  spe- 

'  This  promise,  which  was  announced  in  the  3cl  edition  of  this  work,  is  now  repeated 
with  a  good  prospect  of  its  approaching  fulfilment. 


38  HISTORICAL    SKETCH 

culum,  which  exposes  the  uterus  by  a  new  principle,  and  opens  the 
way  to  a  more  complete  examination  of  that  organ.  Recamier 
marked  an  era  by  improving  our  powers  of  diagnosis  in  exposing 
the  cervix  uteri  ;  Simpson  another,  by  opening  to  investigation  the 
body  of  the  uterus  ;  and  Sims  a  third,  by  rendering  both  investiga- 
tions more  simple,  complete,  and  satisfactory.  The  ordinary  specula 
in  use  before  the  discovery  of  Sims's,  simply  separate  the  vaginal 
walls  mechanically,  and  thus  expose  the  uterus.  Sims's  instrument, 
on  the  other  hand,  elevates  the  posterior  vaginal  wall,  which  allows 
the  entrance  of  air  to  distend  the  whole  passage,  the  woman  lying 
on  her  side  in  such  a  manner  that  the  cavity  can  be  probed  with 
the  most  perfect  ease,  and  applications  made  to  the  fundus.  I  am 
fully  aware  that  many  willdifter  from  me  in  this  opinion,  but  being 
entirely  free  from  prejudice  in  favor  of  this  instrument,  or  against 
the  ordinary  varieties,  I  maintain  it  fearlessly,  feeling  confident 
that  time  will  prove  it  to  be  correct.  No  one  who  has  not  tested 
the  two  methodsof  examination  is  really  entitled  to  an  opinion  u[»on 
the  point,  and  I  cannot  doubt  the  conclusion  of  him  who  has  done 
80  faithfully  and  intelligently. 

It  may  very  pertinently  be  asked  how  I  reconcile  this  opinion 
with  the  facts  that  with  the  exception  of  myself  no  other  writer 
of  a  systematic  treatise  on  gynecology  recommends  this  method  of 
exploration  in  preference  to  that  by  the  cylindrical  s{)eculum  in 
daily  practice;  that  few  if  any  of  the  gynecologists  of  Great  Britain 
or  the  continent  of  Europe  employ  it  to  the  exclusion  of  the  old 
plan  in  ordinary  cases,  and  that  even  in  this  city,  where  the  personal 
advocacy  of  Sims  himself  and  the  wide  spread  influence  of  the 
Woman's  Hospital  which  he  has  founded  are  felt,  only  a  dozen  prac- 
titioners do  so,  most  of  whom  are  connected  with  this  hospital.  My 
explanation  of  the  fact  is  this :  to  employ  Sims's  speculum  efficiently 
considerable  experience  with  it  is  necessary.  One  who  has  not 
practised  with  it  so  as  to  become  skilful  will  find  it  far  less  useful 
than  the  cylindrical  and  valvular  specula  in  ordinary  use.  I  feel 
sure  that  most  of  those  who  have  tried  it  and  cast  it  aside,  except  for 
operations  in  the  vagina  or  uterus,  have  attributed  their  own  short- 
comings to  an  instrument  the  use  of  which  they  had  not  mastered. 
Again,  it  is  necessary  to  have  an  assistant,  and  highly  desirable  to 
have  a  practised  assistant,  to  hold  the  speculum.  None  of  the  sub- 
stitutes for  such  an  assistant  have  ever  proved  or,  I  think,  will  ever 
prove  effectual.  For  this  reason  also  the  use  of  this  instrument  has 
not  become  more  general. 

It  is  becoming  customary  with  those  who  practise  gynecology  as 


OF    GYNECOLOGY.  39 

specialists  in  this  city  and  employ  this  speculum,  to  see  their  patients 
almost  universally  at  their  offices,  and  to  have  in  attendance  a  trained 
nurse  who  manages  both  patient  and  instrument  during  examina- 
tions. One  practising  in  this  manner  places  himself,  I  am  conlident, 
on  a  vantage  ground,  which  can  scarcely  be  imagined  by  him  who 
clings  to  the  old  methods  of  exploration.  The  experience  required, 
however,  to  use  this  speculum  with  advantage,  and  the  disadvan- 
tage of  its  requiring  the  aid  of  a  nurse,  will  prevent  its  universal  or 
even  very  general  adoption.  I  do  not  believe  that  the  practitioner 
who  sees  very  little  of  uterine  disease  will  ever  employ  it.  But 
there  are  at  present  many  who  are  studying  and  practising  gyne- 
cology extensively  and  scientifically.  It  is  to  such  that  these  re- 
marks are  especially  addressed. 

In  stating  all  this  thus  plainly  and  positively,  I  am  by  no  means 
ignorant  of  the  criticism  to  which  I  expose  myself  from  an  over- 
whelming and  most  influential  majority.  I  confess  that  even  to 
me  the  slow  advance  made  by  Sims's  speculum,  as  an  instrument  for 
every-day  use,  has  been  a  matter  of  great  surprise.  Familiarized, 
however,  by  years  of  practice  with  both  methods  of  examination, 
and  prejudiced  in  favor  of  neither,  I  cannot  doubt  the  result.  The 
assertion  of  its  rights  by  the  new  method  will  give  an  impetus  to  the 
advance  of  gynecology  which  in  some  degree  it  has  even  now  effected. 

I  cannot  close  this  part  of  my  subject  without  appealing  to  those 
working  in  this  department  who  are  willing  to  test  the  matter,  in 
the  following  manner.  Learn  the  use  of  Sims's  speculum,  not  by 
personal  labor  and  experiment,  but  from  one  who  is  fully  master  of 
it ;  have  at  your  disposal  a  trained  nurse,  and  persevere  with  the 
method  for  three  months,  and  you  will  endorse  the  statement  as  to 
the  vantage  ground  which  you  will  occupy,  which  just  now  appears 
so  exaggerated  to  you.  Kothing  is  easier  than  to  attack  iipon 
l^aper  such  a  position  as  that  which  I  have  here  assumed.  Is^othing 
more  tempting  than  a  half  humorous,  half  sarcastic  review  of  it. 
But  the  question  is  one  of  too  great  moment  to  be  thus  dealt  with. 
All  earnest  workers  in  our  ranks  are  in  search  after  truth,  not 
striving  to  prove  themselves  right;  all  wise  men  are  eager  to  avail 
themselves  of  improvements  in  their  calling,  not  to  find  warrant 
for  hugging  what  is  old. 

Within  the  last  quarter  of  a  century  a  vigorous  attempt  has  been 
made  to  open  the  field  of  gynecology  to  female  labor,  and  to  ])lace 
it  and  its  sister  branch,  obstetrics,  to  as  great  an  extent  as  possible, 
under  the  management  of  female  practitioners.  For  this  purpose 
female  medical  colleges  have  been  established  in  Il^ew  York,  Phila- 


40  HISTORICAL    SKETCH 

(lelphia,  and  other  cities  of  America ;  and  of  late  the  English 
journals  inform  us  of  the  foundation  of  one  in  London.  In  France 
a  proportion  of  the  work  has,  for  a  long  time,  been  allotted  to  the 
"Sages  Femmes,"  or  midvvives.  Many  of  those  who  foster  the 
attempt  appear  to  regard  it  as  a  novel  one,  and  reiterate  the  asser- 
tion that  woman  has  never  been  allowed  a  fair  trial  in  this,  her 
most  appropriate  sphere  of  action.  This  is  a  great  error.  Not 
only  has  the  way  been  open  to  her  as  competitor  with  man,  but  at 
times  it  has  been  almost  entirely  relinquished  to  her  keeping.  If 
success  has  not  attended  her  efforts,  it  has  been  due,  not  to  want 
of  opportunity,  but  of  capacity  or  adaptation.  Aetius  makes  men- 
tion of  the  writings  and  practice  of  Aspasia,  who  was  a  doctress  at 
Ron;ie  about  the  third  century,  and  copies  extensively  from  her 
upon  ulceration  and  displacements  of  the  womb.  Paulus  -^Egineta 
is,  for  some  of  his  chapters,  indebted  to  Cleopatra,  fragments  of 
whose  writings  he  has  })reserved  for  us.  He  evidently  quotes  her 
with  respect,  and  credits  her  with  what  he  borrows.  In  the  thir- 
teenth century  an  Arabian  woman,  Trotula  by  name,  published  a 
treatise,  in  which  she  mentions  that  many  Saracenic  women  prac- 
tised the  art  of  obstetrics  at  Salerno.  In  later  times,  during  the 
eighteenth  and  nineteenth  centuries,  women  were  graduated  as 
Doctors  of  Medicine  in  the  Italian  Universities,  and  as  such  enjoyed 
great  consideration.  In  1732,  La  Dottoressa  Laura  Bassi  graduated 
at  Bologna,  and  filled  the  chair  of  JS^atural  Philosophy  for  six  years. 
In  the  last  part  of  the  eighteenth  century,  Madonna  Manzolina 
lectured  on  anatomy  at  Bologna,  while  others  of  lesser  note  filled 
positions  of  minor  importance.  The  women  of  Greece  and  Home 
approached  the  task  as  well  prepared  to  meet  its  re(|uirements,  both 
mentally  and  physically,  as  do  those  of  our  day;  and  surely  no  lack 
of  opportunity  could  have  been  complained  of  by  the  successors  of 
Agnodice.^  Those  of  the  Arabian  civilization  had  not  only  oppor- 
tunity, but  the  incentive  of  duty,  to  urge  them  on  to  the  acquire- 
ment of  knowledge  and  skill ;  for  so  great  were  the  sensuality  and 
libertinism  of  the  Saracens,  that  the  Mahommedan  laws  prohibited 
the  attendance  of  males  upon  females  ;  and  thus  their  whole  treat- 
ment, except  in  extreme  cases,  devolved  upon  the  raidwives. 

No  one  of  extended  views  can  desire  to  see  the  doors  of  science 


'  The  story  of  this  physician  is  worthy  of  note.  Contrary  to  the  existing  laws, 
she  studied  medicine,  met  with  great  success  under  the  disguise  of  a  man,  was 
accused  of  corruption  and  brought  to  trial.  Making  her  sex  known  to  the  judges, 
she  was  not  only  acquitted,  but  a  law  was  passed  allowing  all  free-born  women  to 
study  medicine  in  future. 


OF    GYNECOLOGY.  41 

shut  against  any  who  are  sincere  in  their  wish  to  engage  in  its  pur- 
suits;  nevertheless,  there  is  no  resisting  the  evidence  of  history, 
that,  in  spite  of  opportunities  and  incentives,  female  practitioners 
have  failed  in  times  past,  not  only  to  advance,  but  even  to  main- 
tain the  integrity  of  the  art  intrusted  to  their  hands.  The  expe- 
rience of  the  future  may  contradict  that  of  the  past;  but  even  its 
doing  so  will  otfer  no  good  reason  for  despising  the  lesson  whicli 
the  past  has  left  on  record. 

The  opportunity  which  is  now  offered  them  for  retrieving  what 
has  been  lost  in  former  ages  is  certainly  all  that  the  most  exacting 
of  modern  reformers  could  require.  The  prejudice  which  for  years 
existed  against  the  admission  of  females  to  the  practice  of  medicine, 
appears  to  be,  in  this  country  and  in  Europe,  gradually  wearing 
away.  In  this  city,  some  of  the  most  able  of  our  junior  teachers 
are  engaged  in  instruction  in  the  Female  Medical  College,  and 
many  of  the  most  eminent  and  conservative  of  the  senior  members 
of  the  medical  profession,  have  accepted  positions  as  consultants  to 
the  hospital  attached  to  the  college.  Female  practitioners  are 
freely  met  in  consultation  in  general  practice,  and  the  County 
Medical  Society,  one  of  the  two  representative  associations  of  the 
city,  admits  them  to  its  ranks  as  members.  The  general  and 
sincere  feeling  of  the  progressive  and  most  prominent  members  of 
the  medical  profession  here  is  unquestionably  this,  to  allow  to 
females  a  fair  opportunity  to  enter  the  field  of  medicine,  and  strive 
to  establish  their  ability  to  perform  its  arduous  functions,  however 
much  they  may  doubt  the  success  of  the  enterprise  or  deplore  its 
inception.  All  appear  willing  to  intrust  the  solution  of  the  problem 
of  woman's  fitness  for  the  duties  of  medicine  to  time,  the  great 
crucible  of  human  theories. 

I  am  so  often  consulted  by  recent  graduates  as  to  the  works 
which  they  should  make  the  basis  of  a  library  upon  gynecology, 
that  I  feel  that  I  may  render  a  service  by  the  following  list.  Only 
such  works  are  recorded  as  will  prove  of  absolute  service  to  the 
active  practitioner  who  seeks  knowledge  chiefly  upon  practical 
points : — 

Nonat — Maladies  de  I'lJtferus,  1  vol. 

Aran — Maladies  de  I'Uterus,  1  vol. 

Becquerel — Maladies  de  I'Uterus,  2  vols. 

Blatin  et  Nivet — Maladies  des  Ferames,  1  vol. 

West — Diseases  of  Women,  1  vol. 

Tilt — Uterine  and  Ovarian  Inflammation,  1  vol. 

Bennet — On  the  Uterus,  1  vol. 


42  HISTORICAL    SKETCH    OF    GYNECOLOGY. 

Simpson — Diseases  of  Women,  1  vol. 

Hewitt — Diseases  of  Women,  1  vol. 

Churchill — Diseases  of  Women,  1  vol. 

Byford — Medical  and  Surgical  Treatment  of  Women,  1  vol. 

Sims — Uterine  Surgery.  1  vol. 

Baker  Brown — Surgical  Diseases  of  Womeu,  1  vol. 

Tilt — Uterine  Therapeutics,  1  vol. 

Scanzoui — Diseases  of  Females,  1  vol. 

Meigs — Diseases  Peculiar  to  Females,  1  vol. 

Bedford — Diseases  of  Women  and  Children,  1  vol. 

Colombat — On  Females  (annotated  by  Meigs),  1  vol. 

Ashwell — Diseases  of  Women,  1  vol. 

McClintock — Diseases  of  Women,  1  vol. 

Courty — Maladies  de  I'Uterus  et  de  ses  Annexes,  1  vol. 

Hodge — Diseases  Peculiar  to  Women,  1  vol. 

Klob — Pathological  Anatomy  of  the  Female  Genital  Organs,  1  voL 

Spencer  Wells — On  Diseases  of  the  Ovaries. 

Kiwisch — On  Diseases  of  the  Ovaries,  1  vol. 

Wright — Diseases  of  Women,  1  vol. 

Emmet — On  Vesico-Vaginal  Fistulae,  1  vol. 

Duncan — Parametritis  and  Perimetritis,  1  vol. 

Duncan — Fecundity,  Fertility,  and  Sterility,  1  vol. 

Athill — Diseases  of  Women,  1  vol. 

Gallard — Logons  Clinique  sur  les  Maladies  des  Femmes,  1  vol. 

Peaslee — Ovarian  Tumors,  1  vol. 

Atlee — Ovarian  Tumors,  1  vol. 

Barnes — Treatise  on  Diseases  of  Women. 


I 


ETIOLOGY    OF    UTERINE    DISEASES.  43 


CHAPTER   II. 

THE   ETIOLOGY  OF  UTERINE   DISEASES. 

In  investigating  the  causes  of  uterine  diseases  I  shall  refer 
>> especially  to  those  which  are  active  in  this  country.  I  would 
not  be  understood  as  drawing  any  comparison  between  their 
frequency  here  and  abroad,  for  in  the  absence  of  statistical  evi- 
dence such  an  attempt  would  necessarily  be  futile.  It  is  easier, 
however,  to  write  of  habits  which  are  under  our  immediate  obser- 
vation, than  of  those  concerning  which  we  merely  read  and  hear ; 
and  for  this  reason  I  give  myself  the  limits  herein  prescribed.  My 
intention  is  not  in  the  present  chapter  to  review  all  the  causes  of 
uterine  disorders,  but  to  confine  myself  to  the  consideration  of 
I  those  which  are  avoidable,  incurred  merely  from  disregard  of  the 
laws  of  health,  and  which  are  generally  rather  predisposing  than 
exciting.  Others,  which  are  accidental  and  exciting,  will  be  men- 
t  tioned  in  connection  with  special  diseases  as  they  come  under  notice. 
If  we  compare  the  present  state  of  women  in  refined  society  over 
t  the  world  with  that  of  the  working  peasants  of  the  same  latitudes, 
or  with  the  North  American  squaws,  or  the  powerful  negresses  of 
t  the  Southern  States,  we  can  with  difficulty  believe  that  they  all 
sprung  from  the  same  parent  stem,  and  originally  possessed  the 
same  physical  cajtacities.  Observation  proves  that  women  who  are 
not  exposed  to  depreciating  iufiuences  can  compete  in  strength  and 
endurance  with  the  men  of  their  races,  and  in  savage  countries 
t  they  are  sometimes  regarded  as  superior  to  them.  In  the  lower 
orders  of  animals  this  equality  is  still  more  marked.  The  mare 
endures  as  much  as  the  horse,  and  some  of  our  most  celebrated 
racers  have  represented  the  female  sex.  The  lioness  is  fully  as 
dangerous  to  the  hunter  as  her  more  majestic  consort,  and  the 
bitch  proves  as  untiring  in  the  chase  as  the  most  muscular  dog  in 
t  the  pack. 

From  all  these  facts  we  may  logically  argue,  that  the  human 
t  female,  if  properly  developed  and  placed  beyond  causes  which 
'  militate  against  her  physical  well-being,  would  be  in  no  great 
•(degree  the  inferior  of  the  male.  This  position  I  now  assume,  and 
1  maintain  that  the  customs  of  civilized  life  have  depreciated  her 


44  ETIOLOGY    OF    UTERINE    DISEASES. 

[.owers  of  endurance  and  capacity  for  resisting  disease.  My  efforts 
will  be  directed  to  an  endeavor  to  point  out  what  tliese  habits  and 
influences  are.  I  do  not,  of  course,  advance  the  statement  that 
uterine  diseases  are  unknown  among  uncivilized  women,  for  I  have 
too  often  seen  prolapsus,  retroversion,  granular  degeneration,  and 
kindred  disorders  among  the  former  slaves  of  this  country  to  do 
so.  These  affections  were,  however,  rare  among  them,  and  not 
exceedingly  common,  as  they  are  amongst  our  white  women,  and 
even  when  they  existed,  they  did  not  so  profoundly  affect  the  con- 
stitutions of  those  suffering  from  them. 

Those  influences  which,  growing  out  of  civilization  and  refine- 
ment, tend  most  decidedly  to  produce  uterine  disorders  may  thus 
be  enumerated  : — 

Xeglect  of  out-of-door  exercise. 

Excessive  development  of  the  nervous  system. 

Improprieties  of  dress. 

Imprudence  during  menstruation. 

Imprudence  after  parturition. 

Prevention  of  conception  and  induction  of  abortion. 

Marriao;e  with  existing  uterine  disease. 

Want  of  air  and  exercise^  in  deteriorating  the  blood  and  enfeebling 
the  musculnr  and  nervous  systems,  should  be  classed  first  among 
these  predisposing  causes. 

There  can  be  no  doubt  that  American  women  take  much  less 
exercise  than  those  of  Europe.  Walking,  riding,  rownng,  bowling, 
etc.,  which  are  there  so  common,  are  here  not  much  practised.  In 
our  large  cities  will  be  found  hundreds  of  ladies  who  do  not  walk 
a  mile  in  a  day  for  weeks  together,  and  many  more  who  have 
never  engaged  in  an}^  exercise  which  called  forth  the  action  of 
other  muscles  than  those  employed  in  the  quietest  locomotion. 
This  is  partly  due  to  the  fact  that,  with  us,  recreations  w^hich  re- 
quire muscular  efforts  on  the  part  of  women  are  not  fashionable ; 
partlj'  to  a  morbid  desire  to  cultivate  an  appearance  of  delicacy  in 
form  and  complexion  ;  and  in  great  part  to  improprieties  of  dress, 
which  render  it  dangerous  for  them  to  remain  in  the  open  air 
except  in  good  weather.  Instead  of  our  girls  being  encouraged  to 
engage  in  outdoor  pursuits  calculated  to  create  muscular  power, 
they  are  reared  in  the  belief  that  such  pastimes  are  hoydenish, 
unbecoming,  and  fit  only  for  rough  boys.  Their  hours  of  leisure 
are  occupied  by  reading,  music,  drawing,  or  some  similar  light  task, 
and  an  hour's  walk  every  day  is  regarded  as  an  accomplishment 


EXCESSIVE    DEVELOPMEXT    OF    XEUVOUS    SYSTEM.         45 

quite  creditable  to  the  performer.  This  pernicious  system  of  train- 
ins:  is  observed  most  markedly  in  our  larij-e  female  seminaries  or 
boarding-schools,  where  every  hour  of  the  day  is  allotted  by  rule 
to  its  especial  work.  By  this  plan  the  mind  is  constantly  kept  in 
the  thraldom  of  control,  and  chafes  under  the  depressing  influence 
I  A'  a  never-ending  surveillance.  A  set  of  romping  school-girls  could 
as  profitably  laugh  by  rule  as  reall3'  enjoy  and  improve  by  exercise 
under  the  eye  of  an  instructress  or  professor  of  calisthenics.  It 
is  not  the  mere  bodily  exertion  which  is  of  benefit,  but  the  total 
ental  relaxation,  the  exhilaration  and  the  abandon  which  ac- 
'inpany  it.  The  prisoner  working  for  eight  houi-s  on  the  treadmill 
does  not  profit  by  it  as  the  free  and  hajip}'  equestrian  or  oarsman 
does,  by  one-eighth  the  time  of  exercise. 

Excessive  Development  of  the  Nervous  System. — The  necessity  for 
a  due  proportion  existing  between  the  development  and  strength 
of  the  nervous  and  muscular  systems  has  always  been  recognized, 
and  has  given  rise  to  the  trite  formula,  "  mens  sana  in  corpora 
sano,"  as  essential  to  health.  Unfortunately  the  restless,  energetic 
and  ambitious  spirit  which  actuates  the  people  of  the  United  States, 
has  prompted  a  plan  of  educati(ni  which  by  its  severity  creates  a 
vast  disjjroportion  between  these  two  systems,  and  its  eflects  are 
more  especially  exerted  upon  the  female  sex,  in  which  the  tendency 
to  such  loss  of  balance  is  much  more  marked  than  in  the  male. 
'  'iris  of  tender  age  are  required  to  apply  their  minds  too  constantly, 
to  master  studies  which  are  too  difficult,  and  to  tax  their  intellects 
by  eftorts  of  thought  and  memory  which  are  too  prolonged  and 
laborious.  The  results  are,  rapid  development  of  brain  and  nervous 
system,  precocious  talent,  refined  and  cultivated  taste,  and  a  fas- 
cinating vivacity  on  the  one  hand;  a  morbid  impressibility,  gi*eat 
feebleness  of  muscular  system,  and  marked  tendency  to  disease  in 
the  generative  organs,  on  the  other. 

That  this  statement  of  the  advantages  which  are  gained  and  the 
price  which  is  paid  for  them  is  perfectly  true,  no  American  prac- 
titioner will  deny.  But  the  mere  existence  of  the  fact  is  not  the 
most  melancholy  feature  of  the  case;  it  is  far  more  painful  to  see 
mothers  listening  to  it,  admitting  its  truth,  and  yet  calmly  and 
dispassionately  choosing  to  make  the  trial,  as  we  see  them  doing 
every  day. 

In  a  woman  thus  developed,  the  physiological  congestion  of  the 
pelvic  organs  attending  ovulation  produces  pain  which  is  known 
as  "  neuralgic  dysmenorrhoea  ;"  ovulation  becomes   irregular  and 


46  ETIOLOGY    OF    UTERINE    DISEASES. 

jibnornial,  favoring  the  development  of  subacate  ovaritis ;  the  nor- 
mal hypertrophy  of  the  uterus  consequent  upon  utero-gestation 
slowly  and  imperfectly  passes  off,  subinvolution  often  remaining; 
while  the  enfeebled  muscular  supports  of  the  heavy  organ  allow 
it  to  lapse  from  its  position  and  assume  that  of  iiexion  or  ver- 
sion. 

Improprieties  of  Dress. — The  dress  adopted  by  the  women  of  our 
times  may  be  very  graceful  and  becoming,  it  may  possess  the  great 
advantages  of  developing  the  beauties  of  the  figure  and  concealing 
its  defects,  but  it  certainly  is  conducive  to  the  development  of  ute- 
rine diseases,  and  proves  not  merely  a  predisposing,  but  an  exciting 
cause  of  them.  For  the  proper  performance  of  the  function  of  re- 
spiration, an  entire  freedom  of  action  should  be  given  to  the  chest, 
and  more  especially  is  this  needed  at  the  base  of  the  thorax,  oppo- 
site the  attachment  of  the  important  respiratory  muscle,  the  dia- 
phragm. Tlie  habit  of  contracting  the  body  at  the  waist  by  tight 
clothing  confines  this  part  as  if  by  S2:)lints ;  indeed  it  accomplishes 
just  what  the  surgeon  does  who  bandages  the  chest  for  a  fractured 
rib,  with  the  intent  of  limiting  thoracic,  and  substituting  abdomi- 
nal respiration. 

As  the  diaphragm,  thus  fettered,  contracts,  all  lateral  expansion 
being  prevented,  it  presses  the  intestines  upon  the  movable  uterus, 
and  forces  this  organ  down  upon  the  floor  of  the  pelvis,  or  lays  it 
across  it.  In  addition  to  the  force  thus  exerted,  a  number  of  pounds, 
say  from  five  to  ten,  are  bound  around  the  contracted  waist,  and 
held  up  by  the  hips  and  the  abdominal  walls,  which  are  rendered 
protuberant  by  the  compression  alluded  to.  The  uterus  is  exposed 
to  this  downward  pressure  for  fourteen  hours  out  of  every  twenty- 
four;  at  stated  intervals  being  still  further  pressed  upon  by  a  dis- 
tended stomach. 

In  estimating  the  effects  of  direct  pressure  upon  the  position 
of  the  uterus,  its  extreme  mobility  must  be  constantly  borne  in  mind. 
No  more  striking  evidence  of  this  can  be  cited  than  the  fact,  that 
in  examining  it  by  Sims's  speculum,  if  the  clothing  be  not  loosened 
around  the  waist,  the  cervix  is  thrown  so  far  back  into  the  hollow 
of  the  sacrum  as  to  make  its  engagement  in  the  field  of  the  instru- 
ment often  very  difiicult,  and  that  attention  to  this  point  in  the 
arrangement  of  the  patient  will  at  once  remove  the  difliculty. 
While  the  uterus  is  exposed  by  the  speculum,  it  will  be  found  to 
ascend  with  every  expiratory  efibrt,  and  descend  with  every  inspi- 
ration ;  and  so  distinct  and  constant  are  the  rapid  alterations  of 


IMPROPRIETIES    OF    DRESS.  47 

position  thus  induced,  that  in  operations  in  the  vaginal  canal  the 
surgeon  can  tell  with  great  certainty  liow  respiration  is  being 
aiiected  by  the  ansesthetic  employed.  An  organ  so  easily  and  de- 
cidedly influenced  as  to  position  by  such  slight  causes  must  neces- 
sarily be  affected  by  a  constriction  which,  in  autopsy,  will  some- 
times be  found  to  have  left  the  impress  of  the  ribs  upon  the  liver, 
}iroducing  depressions  corresponding  to  them. 

]^()  one  will  charge  me  with  drawing  upon  my  imagination, 
even  in  the  remotest  degree,  for  the  details  of  the  following  pic- 
ture, for  a  little  reflection  will  assure  all  of  its  correctness.  A  lady 
who  has  habitually  dressed  as  already  described,  prepares  for  a  ball 
by  increasing  all  the  evil  influences  which  result  from  pressure. 
Although  she  may  be  menstruating,  she  dances  until  a  late  hour 
of  the  night,  or  rather  an  early  hour  of  the  morning.  She  then  eats 
a  hearty  supper,  passes  out  into  the  inclement  night  air,  and  rides 
a  long  distance  to  her  home.  This  is  repeated  frequently  during 
each  season,  until  advancing  age  or  the  occurrence  of  disease  puts 
an  end  to  the  process. 

A  great  deal  of  exposure  is  likewise  entailed  upon  women  by  the 
uncovered  state  of  the  lower  extremities.  The  body  is  covered, 
hut  under  the  skirts  sweeps  a  chilling  blast,  and  from  the  wet  earth 
rises  a  moist  vapor,  that  comes  in  contact  with  limbs  encased  in 
thin  cotton  cloth,  which  is  entirely  inadequate  for  their  protection. 
It  is  not  surprising  that  evil  often  results  to  a  menstruating  woman 
thus  exposed. 

To  a  woman  who  has  systematically  displaced  her  uterus  by  j^ears 
of  imprudence,  the  act  of  sexual  intercourse,  which,  in  one  whose 
organs  maintain  a  normal  position,  is  a  physiological  process  devoid 
of  pathological  results,  becomes  an  absolute  and  positive  source  of 
disease.  The  axis  of  the  uterus  is  not  identical  with  that  of  the 
vagina.  "While  the  latter  has  an  axis  coincidetit  with  that  of  the 
inferior  strait,  the  former  has  one  similar  to  that  of  the  superior. 
This  arrangement  provides  for  the  passage  of  the  male  organ  below 
the  cervix  into  the  posterior  ciil-de-sac,  the  cervix  thus  escaping 
injury.  But  let  the  uterus  be  forced  down,  as  it  is  by  the  prevail- 
ing styles  of  fashionable  dress,  even  to  the  distance  of  one  inch,  and 
the  natural  relation  of  the  parts  is  altered.  The  cervix  is  directly 
injured,  and  thus  a  physiological  process  is  insensibly  merged  into 
one  productive  of  pathological  results.  IIow  often  do  we  see  uterine 
disease  occur  just  after  matrimony,  even  where  no  excesses  Ijave 
been  committed.  It  is  not  an  excessive  indulgence  in  coition  which 
so  often  produces  this  result,  but  the  indulgence  to  any  degree  on  the 


48  ETIOLOGY  OF  UTERINE  DISEASES. 

part  of  a  woman  who  has  distorted  the  natural  relations  of  the 
genital  organs. 

But  this  is  by  no  means  the  only  method  by  which  disi^lacenient 
of  the  uterus  may  induce  disease  of  its  structures.  It  disorders  the 
circulation  in  the  displaced  organ,  and  produces  passive  congestion 
and  its  resulting  hypertrophy,  prevents  the  free  escape  of  menstrual 
blood  by  pressing  the  os  against  the  vagina,  creates  flexion,  causes 
friction  of  the  cervix  against  the  floor  of  the  }>elvis,  and  stretches 
the  uterine  ligaments  and  destroys  their  power  and  efficiency. 

These  facts  should  be  carefully  borne  in  mind  by  the  physician 
who  attempts  to  relieve  uterine  displacements  by  the  use  of  pessa- 
ries. If  he  merely  rei)laces  the  displaced  organ  and  relies  for  its 
support  upon  a  pessary,  he  will  often  fail  in  accomplishing  the 
desired  result.  He  is  striving  at  great  disadvantage  with  a  short 
lever  power  against  the  weight,  not  of  the  uterus  alone,  but  of  the 
super-imposed  viscera  pressed  downwards  by  several  })onnds  of 
clothing,  which  add  their  weight  at  the  same  time  that  they  con- 
strict the  waist  and  substitute  abdominal  for  thoracic  respiration. 
Thus  employed,  the  pessary  will  often  give  great  pain,  and  so  injure 
the  parts  upon  which  it  rests  as  to  necessitate  removal,  and  the 
practitioner  will  find  himself  cut  oft"  from  one  of  his  most  valuable 
resources.  Should  he,  on  the  other  hand,  before  employing  a  pes- 
sary, remove  all  constriction  and  weight  from  the  abdominal  walls, 
apply  a  well-fitting  abdominal  supporter  over  the  hypogastrium  so 
as  to  aid  the  exhausted  abdominal  muscles  in  their  work,  keep  the 
displaced  and  congested  uterus  out  of  the  cavity  of  the  pelvis  by  a 
tampon  of  medicated  cotton,  or  bring  gravitation  to  his  assistance 
by  the  position  of  the  patient,  he  will  ordinarily  at  the  end  of  a 
week  be  able  to  employ  with  great  advantage  the  same  pessary, 
which  at  first  seemed  to  accomplish  evil  and  not  good. 

Imprvdence  during  3Ienstnmtion  is  a  prolific  source  of  disease. 
Some  women,  through  ignorance,  many  through  recklessness,  and 
a  few  from  necessity,  go  out  lightly  clad  in  the  most  inclement 
weather  during  this  period,  and  many  suffer  in  consequence  from 
violent  congestive  dysmenorrhcea,  and  often  from  endometritis. 
Every  practitioner  will  meet  with  a  certain  number  of  cases  of  ute- 
rine disease  which  have  this  origin,  and  run  on  for  years,  ending, 
perhaps,  in  parenchymatous  disease,  which  may  prove  incurable. 

During  a  period  in  which  the  ovaries  and  uterus  are  intensely 
engorged,  in  which  the  surface  of  the  ovary  is  broken  through  by 
the  escaping  ovule,  and  the  nervous  system  is  in  an  unusual  state 


IMPRUDENCE    AFTER    PARTURITION.  49 

of  excitability,  ordinary  prudence  would  suggest  that  the  body 
should  be  well  covered,  that  the  congested  organs  should  be  left 
at  rest,  and  that  exposure  to  cold  and  moisture  should  be  sedulously 
avoided.  I  need  not  say  that  these  rules  are  commonly  neglected ; 
and  in  evidence  of  the  fact  I  will  venture  the  assertion  that,  on  this 
very  day,  the  thermometer  15°  above  zero,  the  skating  pond  of  our 
park  contains  scores  of  delicate  and  refined  women  who  are  show- 
ing a  disregard  of  them  by  their  presence  there. 

The  immediate  result  of  exposure  during  menstruation  is  most 
commonly  inflammation  of  the  mucous  membrane  of  the  uterus. 
Such  an  inflammation  once  excited  will  often  go  on  for  years  and 
in  time  end  in  parenchymatous  disease,  entailing  in  its  progress 
dysmenorrhoea,  sterility,  pelvic  pain,  and  gastric  disorders,  which 
impair  digestion  and  nutrition. 

Imprudence  after  Parturition. — "Eo  sooner  does  fixation  of  the  im- 
pregnated ovum  upon  the  uterine  surface  occur  than  a  surprising 
stimulation  is  exerted  upon  the  fibre-cells  forming  part  of  the  ute- 
rine parenchyma,  which  grow  with  rapidity,  enlarging  the  organ, 
-pari  passu^  with  the  requirements  of  its  increasing  contents.  After 
the  expulsion  of  the  embryo,  either  at  full  time  or  at  any  period  of 
pregnancy,  the  fibres  thus  develo[)ed  undergo  a  fatty  degeneration 
and  absorption,  which  has  received  the  name  of  involution.  This 
process  occurs  rapidly  after  abortion,  but  after  labor  at  term  it  re- 
quires six  weeks  for  its  full  accomplishment.  In  order  that  it  may 
proceed  with  normal  rapidity  and  certainty,  perfect  rest  is  essential ; 
and  the  woman  who  rises  too  soon,  and  resumes  her  usual  occupa- 
tions, while  the  lochial  discharge  is  still  existing,  risks  the  results 
of  interference  with  it.  Besides  this,  the  uterus  is  much  heavier 
than  usual,  and  the  additional  danger  of  the  induction  of  displace- 
ment is  incurred  by  too  early  exertion.  Lastly,  the  mucous 
membrane  lining  the  cavity  of  the  uterus  is  for  some  time  after 
parturition  in  an  abnormal  state,  and  is  peculiarly  liable  to  disease 
from  exposure  to  cold  and  moisture.  A  very  valid  objection  may 
be  made  to  this  view,  that  in  the  lower  walks  of  life  women  rise 
after  labor,  and  attend  to  their  duties  with  impunity  on  about  the 
ninth  day,  and  yet  enjoy  a  marked  immunity  from  uterine  aflec- 
tions.  This  is  true ;  but  let  it  be  remembered  that  they  are  un- 
aftected  by  the  influences  to  which  I  have  alluded,  as  calculated  to 
enfeeble  and  deteriorate  their  generative  systems. 

Another  influence  connected  with  parturition  which  develops 
itself  much  more  decidedly  among  the  higher  than  the  lower 
4 


50  ETIOLOGY    OF    UTERINE    DISEASES. 

classes,  is  the  pernicious  habit  of  tiglit  bandaging.  For  three  or 
four  weeks  after  delivery  the  nurse  commonly  applies  two  folded 
towels  over  the  enlarged  uterus,  and  by  powerful  compression  by 
a  bandage  forces  the  organ  backwards  into  the  hollow  of  the  sacrum. 
This  is  supposed  to  preserve  the  comeliness  of  the  figure,  and  the 
reputation  of  many  a  nurse  rests  mainly  upon  the  thoroughness 
with  which  she  develops  an  influence  that  is  fruitful  of  evil  in  dis- 
placing an  enlarged  uterus  in  a  woman  who  for  a  fortnight  at  least 
lies  chiefly  upon  her  back.  That  a  well-fitting  bandage,  only  tight 
enough  to  give  support,  applied  after  delivery  proves  a  source  of 
comfort  to  the  woman,  I  am  not  disposed  to  deny.  In  this  way  I 
always  employ  one.  But  I  feel  very  sure  that  a  great  deal  of  super- 
stition attaches  in  the  lying-in  room  to  this  appliance  both  as  a 
means  of  preventing  deterioration  of  the  figure,  and  post-partum 
hemorrhage.  Uterine  contraction  should  be  secured  by  vital,  not 
mechanical  means,  and  no  amount  of  compression  by  a  bandage 
will  cause  the  over-distended  abdominal  muscles,  skin,  fascise,  and 
areolar  tissue  to  ret  urn  to  their  original  condition.  Not  only  should 
tight  bandaging  be  avoided  after  delivery,  the  position  should  be 
systematically  changed  at  intervals  from  the  dorsal  to  the  lateral 
decubitus.  I  am  convinced  that  uterine  displacement  is  one  of  the 
most  fruitful  causes  of  subinvolution.  As,  during  the  six  weeks  or 
two  months  succeeding  delivery,  the  process  of  retrograde  meta- 
morphosis, called  involution,  progresses,  the  uterus,  under  untoward 
influences,  many  of  which  are  developed  by  the  routine  manage- 
ment of  the  lying-in  chamber,  becomes  displaced.  This  results  in 
impeded  venous  return  from  its  tissues ;  the  process  of  involution  is 
checked,  and  months  or  years  afterwards  the  patient,  being  forced 
to  apply  to  a  physician,  is  informed  that  she  has  sufliered  and  is 
suffering  from  metritis  of  a  chronic  character  of  which  displacement 
is  a  complication  or  result. 

Every  practitioner  frequently  hears  that  some  lady  has  been  in- 
jured for  life  "because  she  was  not  properly  bandaged  at  her  last 
confinement,"  and  either  doctor  or  nurse,  possibly  both,  are  severely 
censured  for  the  culpable  neglect.  Too  often  such  censure  is  lis- 
tened to  in  silence,  and  the  party  supposing  herself  injured  is  allowed 
to  hold  the  same  opinion  still.  It  is  the  duty  of  every  physician 
to  inform  those  coming  under  his  influence  as  to  the  futility  of 
trusting  to  the  obstetric  bandage,  or  if  he  cannot  conscientiously 
do  so,  it  is  full}^  ns  much  his  duty  to  review  his  opinion  upon  the  1 
8ul)jeet,  and  carefully  to  consider  whether  his  own  confidence  is  not 
misplaced. 


PREVENTION    OF    CONCEPTION  —  ABORTION.  51 

Preventio7i  of  Conne2)tion  and  Induction  of  Abortion. — Means  estab- 
lished for  the  aceomplishment  of  the  lirst  of  these  ends  are  often 
productive  of  uterine  disorder.  This  will  not  be  wondered  at  when 
the  harshness  of  some  of  them  is  borne  in  mind.  The  workings  of 
nature  in  this,  as  in  all  other  physiological  processes,  are  too  per- 
fect, too  accurately  and  delicately  adjusted,  not  to  be  interfered 
with  materially  by  the  clumsy  and  inappropriate  measures  adopted 
to  frustrate  them.  The  practice  is  becoming  exceedingly  com- 
mon, as  every  physician  is  aware,  so  common,  indeed,  that  in  the 
older  portions  of  this  country,  (unfortunately  it  must  be  said  in  the 
more  civilized  and  educated,)^  it  is  by  no  means  usual  to  meet 
with  large  families  of  children. 

This  question  is  certainly  not  an  agreeable  one  to  deal  with,  and 
the  facts  which  I  am  citing  may  prove  unacceptable  to  many  of  my 
countrymen,  but  it  is  one  which  is  rapidly  assuming  proportions 
which  must  influence  the  future  population  of  our  country.  It  is 
useless  to  ignore  it.  If  an  evil  is  to  be  eradicated,  the  first  step 
towards  such  a  consummation  is  its  recognition,  and  what  class  of 
men  can  more  immediately  and  effectually  grapple  with  this  one 
than  phj-sicians?  That  it  has  attracted  the  attention  of  those  out- 
side of  our  profession,  is  attested  by  the  fact  that  it  has  recently 
been  made  a  subject  of  consideration  in  a  pastoral  letter  from  one 
of  the  Episcopal  bishops  of  the  State  of  K'ew  York  to  the  people 
of  his  diocese. 

"With  these  statements  we  leave  this  unattractive  subject  to  deal 
with  another,  which,  from  its  importance,  cannot  conscientiously 
be  passed  over  in  silence.  Statistics  showing  the  frequency  of 
criminal  abortion  have  never  been,  and  never  will  be  written,  for 
the  crime  creeps  stealthily,  beneath  the  scrutiny  of  society,  and, 
for  some  unaccountable  reason,  without  material  interference  from 
the  judiciary.  It  is,  I  feel,  a  bold  statement,  that,  while  the  law 
pursues  with  relentless  vigor  the  man  who  murders  his  fellow,  it 
allows  immunity  to  him  who  murders  the  young  child  in  its 
mother's  womb;  and  yet  it  is  wellnigh  correct.  Let  me  point  to 
a  few  facts  which  will  substantiate  this  assertion,  and  the  addi- 
tional one  that  this  crime  is  with  us  one  of  fearful  frequency.  On 
my  table  at  this  moment  lies  one  of  the  most  popular  and  best 
edited  daily  journals  of  l!^ew  York — one  which  finds  its  way  into 
the  first  circles  of  society,  and  into  the   hands  of  maidens   and 

'  Able  papers  upon  this  subject  appear  in  the  Boston  Gynecological  Journal, 
from  the  pen  of  Prof.  D.  ITumplircy  Storer,  and  in  the  Philadelphia  Med.  Times, 
from  that  of  Prof.  Wm.  Goodell. 


52  ETIOLOGY    OF    UTERINE    DISEASES. 

matrons  throughout  the  hand.  In  its  columns  are  a  number  of 
advertisements  well  known  as  being  those  of  professional  abor- 
tionists— men  and  women  who  make  a  business  of  infantile  murder. 
It  may  be  that  the  editors,  who  are  esteemed  amongst  us  as  upright 
men,  it  may  be  that  the  police,  are  entirely  ignorant  of  these  focts; 
bat  it  is  hard  to  believe  so,  when  many  of  these  advertisements 
announce  distinctly  the  advantages  of  their  having  rooms  in  which 
their  patients  may  be  accommodated,  and  that  one  interview 
always  accomplishes  the  desired  result,  without  the  use  of  means 
dangerous  to  life  or  health.  At  its  last  meeting  in  New  York,  the 
American  Medical  Association  offered  a  prize*  for  a  "  short  and 
comprehensive  tract  for  circulation  among  females,  for  the  purpose 
of  enlightening  them  upon  the  criminality  and  physical  evils  of 
forced  abortions." 

However  much  I  may  desire  reformation  in  this  matter,  it  is  not 
in  the  spirit  of  a  reformer  that  all  this  is  written.  I  am  not  raising 
my  voice  against  a  great  national  crime,  but  am  striving  merely 
to  estal)lish  the  truth  of  my  statement,  that  this  crime  is  so  frequent 
as  to  constitute  in  all  classes  of  society,  for  it  is  limited  to  none, 
a  great  cause  of  uterine  disease. 

Marriage  with  Existing  Uterine  Disease. — It  is  a  common  practice 
with  phj^sicians  to  recommend  marriage  as  a  cure  for  uterine  dis- 
ease. There  are  a  sufficient  number  of  abnormal  conditions  which 
childbearing  cures  to  make  the  practice  appear  legitimate,  but  a 
vast  deal  of  harm  frequently  results  from  it.  A  constricted  cervix 
which  causes  dysmenorrlia3a,  a  pure  endometritis  of  neck  or  body, 
or  an  inactive  state  of  the  ovaries  which  results  in  amenorrhoea, 
maybe  relieved  by  the  parturient  act;  but  parenchymatous  dis- 
ease, peri-uterine  cellulitis  or  pelvic  peritonitis,  will  very  often  pro- 
duce evil  results  after  labor,  and  very  generally  return  with  re- 
newed violence  as  soon  as  involution  has  been  accomplished.  The 
advice  is  too  often  given  empirically,  and,  like  all  such  counsel, 
is  hazardous  in  its  results.  My  experience  leads  me  to  fear  a 
return  of  such  conditions  after  childbearing,  even  in  a  i)atient 
whom  I  considered  cured  at  the  time  of  marriage. 

Much  injury  has  been  done,  and  a  strong  position  weakened  by 
the  insisting  of  overzealous  persons  upon  isolated  causes  as  pro- 
ductive of  injury  to  females.    Chapter  upon  chapter  has  been  written 


i 


'  The  prize  thus  offered  was  awarded  to  Prof.  H.  R.  Storer,  of  Boston,  for  an 
able  essay,  entitled  "  Why  Not?" 


ETIOLOGY    OF    UTERINE    DISEASE.  53 

ao-ainst  tight-lacing,  for  instance,  in  so  vehement  a  style  that  the 
reader,  if  she  did  not  reflect,  might  suppose  that  to  this  abuse  could 
be  traced  the  whole  catalogue  of  feminine  ills.  If  perchance,  how- 
ever, she  inspected  the  unyielding  stays  which  once  compressed  the 
sturdy  form  of  Alice  Bradford,  and  which  are  now  preserved  in 
Pilgrim  Hall,  in  Plymouth,  she  would  at  once  see  that  the  indict- 
ment was  not  a  valid  one ;  and  similar  objections  might  be  raised 
against  all  the  other  causes  which  I  have  advanced,  viewed  as 
isolated  influences. 

The  Indian  squaw  or  Southern  freedwoman  may  go  half  naked 
while  menstruating,  carry  heavy  burdens  from  morning  till  night, 
or  rise  to  labor^  or  to  travel  in  a  day  or  two  after  parturition,  and 
yet  no  evil  will  result ;  but  to  the  civilized  woman  any  one  of  these 
imprudences  may  prove  a  source  of  disease.  It  is  the  combination 
of  evil  influences,  or  the  action  of  a  single  cause  on  a  sj'stem  so 
deteriorated  by  others  as  to  be  made  incapable  of  resisting  it,  which 
produces  the  unhappy  climax. 

No  one  will  doubt  the  conclusion,  that  if  in  cold  weather  the 
feet,  legs,  and  abdomens  of  civilized  women  were  clad  in  some 
woollen  material ;  if  they  understood  the  necessity  of  caution  dur- 
ing the  period  of  menstruation  and  after  labor ;  if  they  allowed  the 
uterus  to  hold  its  proper  place  in  the  pelvis,  uninterfered  with  by 
pressure;  if  they  kept  the  sanguineous  and  nervous  systems  in 
their  normal  state  of  vigor  by  exercise,  fresh  air,  and  plenty  of 
good  food,  and  at  the  same  time  avoided  any  habits  which  directly 
produce  disease  by  injuring  the  genital  organs,  much,  very  much 
less,  of  uterine  and  kindred  disorders  would  be  seen  by  the  physi- 
cian. All  these  reforms  would  probably  bring  forth  results  in  one 
generation,  but  it  would  require  many  generations  of  reformers  to 
restore  woman  to  her  proper  physical  sphere. 

Before  any  improvement  is  attained  in  this  or  any  other  matter, 
its  importance  must  be  estimated  by,  and  a  desire  for  it  cultivated 
in,  those  whom  it  most  nearly  concerns.  Neither  appreciation  of, 
nor  desire  for,  physical  excellence  sufficiently  exists  among  the 
refined  women  of  our  day.  Our  young  women  are  too  willing  to 
be  delicate,  fragile,  and  incapable  of  endurance.  They  dread 
above  all  things,  the  glow  and  hue  of  health,  the  rotundity  and 

'  In  this  statement  I  do  not  desire  to  reiterate  a  report  whicli  has  long  been 
silenced — that  uncivilized  women  enjoy  an  immunity  from  uterine  disorders.  I 
merely  assert  what  my  own  observation  puts  beyond  doubt  in  my  mind,  that  they 
suffer  little  from  them  in  comparison  with  the  civilized  and  refined. 


54  MEANS    OF    DIAGNOSIS. 

beauty  of  muscularity,  the  comely  shape  which  the  great  masters 
gave  to  Venus  de  Medici  and  Venus  de  Milo.  All  these  attributes 
are  viewed  as  coarse  and  unladylike,  and  she  is  regarded  as  most 
to  be  envied  whose  complexion  wears  the  livery  of  disease,  whose 
muscular  development  is  beyond  the  suspicion  of  embonpoint,  and 
whose  waist  can  almost  be  spanned  by  her  own  hands.  As  a  re- 
sult, how  often  do  w^e  see  our  matrons  dreading  the  process  of 
childbearing  as  if  it  were  an  entirely  abnormal  and  destructive 
one ;  fatigued  and  exhausted  by  a  short  walk  or  their  ordinary 
household  cares ;  choosing  houses  with  special  reference  to  freedom 
from  one  extra  flight  of  stairs,  and  commonly  debarred  the  great 
maternal  privilege  of  nourishing  their  own  offspring.  These  are 
they  who  furnish  employment  for  the  gynecologist,  and  who  fill 
our  homes  with  invalids  and  sufferers. 


CHAPTER    III. 

DIAaNOSIS  OF  THE  DISEASES  OF  THE  FEMALE  GENITAL  ORGANS. 

The  diagnosis  of  the  diseases  of  the  pelvic  viscera  of  the  female 
ofi:ers  many  obscurities,  and  frequently  foils  the  most  careful  and 
capable  practitioners.  With  the  utmost  caution,  assisted  by  the 
most  practised  skill,  no  one  can  avoid  occasional  errors,  while  in 
the  experience  of  those  not  possessing  these  qualifications,  they 
must  be  frequent  and  glaring.  The  only  safeguard  which  can  be 
established  against  their  occurrence,  and  the  only  guarantee  which 
can  be  obtained  for  success,  in  prognosis  and  treatment,  is  the  tho- 
rough mastery  of  the  subject  which  is  now  to  engage  us. 

It  is  not  rare  for  one  making  a  special  study  of  gynecology  to 
find  those  less  familiar  with  it  committing  errors  of  diagnosis,  or, 
what  is  more  common,  arriving  at  no  conclusion,  in  cases  which 
are  perfectly  simple  and  present  no  obscurities  whatever.  When 
meeting  such  instances  in  the  practices  of  intelligent  men,  I  have 
been  struck  by  the  fact  that  the  source  of  difficulty  is  almost 
always  the  same.  The  failure  of  diagnosis  has  not  been  due  to  their 
having  drawn  incorrect  conclusions  from  diagnostic  means,  but  to 
their  not  having  brought  these  means  fully  into  action,  and  pro- 


DISEASES    OF    FEMALE    GENITAL    ORGANS.  55 

perly  applied  them  to  the  solution  of  the  case  in  hand.  In  many 
instances,  uterine  disease  being  suspected,  the  physician  employs 
vaginal  touch,  and  follows  it  by  the  speculum.  If  the  os  and 
cervix  be  diseased,  he  is  successful  in  diagnosis;  but  if  not,  he 
becomes  discouraged,  forgetful  of  the  fact  that  rectal  touch,  the 
uterine  probe,  dilatation  by  tents,  conjoined  manipulation  and  other 
means,  should  be  resorted  to,  and  that,  without  appealing  to  these, 
even  the  most  skilful  diagnostician  would  be  as  helpless  as  himself. 
There  are  means  at  our  command  for  exploring  every  tissue  within 
the  pelvis ;  the  uterus,  the  ovaries,  the  areolar  tissue,  etc. ;  and 
until  they  are  brought  into  service  carefully,  systematically,  and 
thoroughly,  no  one  can  feel  that  he  has  done  justice  to  his  powers 
of  diagnosis,  or  allowed  himself  a  full  opportunity  for  drawing  cor- 
rect conclusions.  Skill  in  diagnosis  must  be  obtained  at  the  bed- 
side, but  for  that  school  to  be  made  profitable,  the  student  must 
have  a  thorough  familiarity  with  the  theory  of  the  means  of  in- 
vestigation which  he  is  there  to  apply.  Having  mastered  these,  let 
him  in  an  obscure  case  develop  them  one  after  the  other,  slowly, 
carefully,  and  thoughtful!}^,  until  he  has  arrived  at  a  diagnosis,  or 
at  the  fact  that  he  is  unable  to  make  one  even  after  having  availed 
himself  of  all  the  resources  at  his  command. 

Let  me  illustrate  this  by  a  supposititious  case.  An  inexperienced 
examiner  discovers  upon  vaginal  touch  that  the  vagina  is  occupied 
by  a  large  tumor.  If  he  rest  satisfied  with  this  method  of  explora- 
tion, and  without  reflection  adopt  the  idea  that  the  case  is  one  of 
fibrous  polj'pus,  he  may  commit  a  grave  error.  The  most  skilful  of 
gynecologists  could  not  decide  by  touch  alone,  and  would  be,  almost 
as  much  as  he,  exposed  to  error  if  he  relied  upon  it.  All  the  means 
which  the  experienced  diagnostician  can  bring  to  his  aid  are  likewise 
at  the  service  of  the  inexperienced ;  and  if  the  former  stand  in  need  of 
their  assistance,  surely  the  latter  much  more  decidedly  requires  it. 
Let  him  then  ask  himself  this  question,  although  he  may  feel  abso- 
lutely positive,  altogether  certain,  that  he  is  dealing  with  a  fibrous 
polypus:  what  else  may  this  be?  At  once  the  answer  will  come,  it 
may  be  a  case  of  prolapsed  uterus,  or  of  inversion  of  the  uterus.  It 
is  important  that  he  should  know  which  it  is,  and  usually  it  is  quite 
easy  to  decide. 

Drawing  down  the  tumor,  he  examines  by  inspection  and  touch, 
and  seeks  the  os  externum,  up  which  to  pass  the  sound.  It  is  not  any- 
where to  be  found,  and  moreover  the  tumor  is  larger  below  than  it  is 
above.  The  case  is  not  one  of  prolapsus,  and  he  feels  that  his  diag- 
nosis of  polypus  is  surely  correct.     If  it  be  a  polypus  which  occupies 


56  MEANS    OF    DIAGNOSIS. 

the  vao;ina,  the  uterus  should  be  above  it.  He  now  practises  con- 
joined nianipuhition,  but  to  his  surprise  this  organ  is  nowhere  to  be 
felt.  This  may  be  due  to  his  want  of  experience,  and  he  examines 
further  with  the  sound,  endeavoring  to  pass  it  alongside  of  the  neck 
of  the  tumor,  and  into  the  uterine  cavity.  He  is  surprised  again,  to 
find  that  it  is  arrested  at  the  neck  of  the  tumor,  around  which  he 
now  passes  his  finger,  and  finds  it  closed  everywhere  by  a  gutter 
of  circular  character  existing  about  an  inch  above  the  lips  of  the 
dilated  os.  The  case  now  looks  like  one  of  inversion,  but  he  is  not 
sure,  for  sometimes  adhesive  inflammation  attaches  the  walls  of 
the  cervix  to  the  neck  of  a  polypus.  Are  there  any  means  by  which 
he  may  settle  this  question  positively?  By  conjoined  manipu- 
lation he  thinks  that  he  feels  a  ring  or  circle  over  the  abdominal 
face  of  the  tumor,  and  gradually  he  pushes  his  fingers  into  it,  and 
becomes  positive  of  its  existence.  Shaving  oft'  a  small  piece  of  the 
mucous  membrane  which  covers  the  vaginal  face  of  the  tumor,  he 
now  places  it  under  the  microscope,  and  finds  it  sparsely  covered 
over  with  cylindrical  or  columnar  epithelium,  not  the  squamous 
epithelium  which  should  characterize  the  surface  of  a  polypus. 

Now  placing  the  patient  upon  the  back  he  passes  one  finger  into 
the  rectum  and  a  sound  into  the  bladder  and  approximates  them 
above  the  tumor.  He  finds  no  uterus  intervening,  and  his  diag- 
nosis is  made;  the  case  is  one  of  inversion  of  the  uterus.  This  is 
his  diagnosis,  that  is,  his  deduction  carefuUj'  and  philosopliically 
drawn  from  the  premises  presented  to  him,  by  the  best  means  at  his 
disposal.  Let  him  resort  to  all  these  means,  and  success  will  usu- 
ally be  his.  But,  it  may  be  suggested,  he  is  not  as  familiar  with 
these  means  as  a  more  experienced  man  is.  Practically,  I  agree 
that  he  is  not ;  but  why  is  he  not  theoretically  ?  Are  they  not  re- 
corded and  fully  explained  in  all  his  works  on  gynecology?  What 
is  demanded  of  him  is  not  experience,  not  wisdom ;  but  a  faithful 
and  earnest  effort  to  arrive  at  the  truth  by  simply  employing  means 
which  science  places  at  his  disposal. 

These  remarks  of  course  apply  with  equal  force  to  every  condi- 
tion in  which  a  diagnosis  is  required.  Let  it  be  a  constant  habit 
to  demand  of  one's  self,  after  admitting  a  suspicion  as  to  the  nature 
of  the  disease,  what  else  could  present  the  physical  appearances 
which  exist?  Having  carefully  considered  this,  let  the  various 
means  of  ditferentiation  at  command  be  full}^  tested.  Then  if  an 
error  of  diagnosis  creep  in  to  damage  interests  entrusted  to  his 
charge,  the  mortified  diagnostician  may  console  himself  with  the 
reflection  that  at  least  he  has  exerted  himself  to  the  utmost  of  his 


RATIONAL    SIGNS.  57 

ability  to  avoid  it,  not  fallen  into  a  trap  set  for  him  by  carelessness, 
indolence,  or  incompetency. 

It  must  not  be  forgotten,  however,  that  certain  rare  and  excep- 
tional cases  will  occasionally  occur,  the  diagnosis  of  which  will 
baffle  the  skill  and  experience  of  the  most  cautious  and  conscien- 
tious. Take,  for  example,  the  following  :^  a  patient  aged  62  years 
Ijad  a  movable  abdominal  tumor  which  was  examined  by  a  number 
of  physicians.  She  died  suddenly,  and  autopsy  revealed  extra- 
uterine pregnancy,  a  child  weighing  4|-  pounds  lying  loose  in  the 
peritoneal  cavity.  Or  this -.^  a  tumor  is  discovered  in  the  pelvis; 
the  patient  dies  from  some  cause  disconnected  with  it,  and  it  is 
found  to  be  a  displaced  kidney.  But  such  cases  are  rare.  The 
careful  and  intelligent  diagnostician  will  very  generally  be  suc- 
cessful. 

Rational  Signs. 

In  the  examination  of  a  patient  suspected  of  having  uterine 
disorder  no  direct  or  suggestive  questions  should  be  asked,  but  the 
symptoms  should  be  drawn  forth  by  encouraging  and  properl}'' 
directing  her  narrative  of  her  case.  Certain  signs  which  we  call 
"rational,"  from  their  appealing  to  our  reason  and  not  to  our 
senses,  such  as  pain  in  the  head,  back,  and  limbs,  menstrual  dis- 
order, leucorrhoea,  impeded  locomotion,  derangement  of  the  diges- 
tion, and  nervous  manifestations,  will  lead  us  to  suspect  the  genital 
organs,  and  may  even  convince  us  of  the  existence  of  disease  there. 
Generally,  however,  they  result  in  the  adoption  of  other  and  more 
certain  means  of  diagnosis,  which  are  termed  "physical." 

Every  one  will,  after  due  experience,  adopt  some  system  by 
which  his  examination  of  patients  will  be  expedited,  and  the 
certainty  of  arriving  at  a  correct  diagnosis  be  increased.  The  plan 
which  I  consider  best  adapted  to  these  ends  is  that  which  follows: 

1st.  The  personal  history,  age,  etc.,  of  the  patient  should  be  ob- 
tained. 

2d.  The  duration  of  the  illness  should  be  fixed. 

3d.  The  history  of  the  attack  from  commencement  to  date  should 
be  elicited. 

4th.  The  present  state  of  the  patient  should  be  ascertained. 

In  obtaining  the  history  of  the  disease,  no  leading  questions  have 
thus  far  been  asked  ;  the  patient  has  told  us  what  she  herself  has 

'  N.  Y.  Med.  Eecord,  Feb.  1st,  1872,  p.  539. 
2  Braithwaite's  Retrospect,  part  37. 


58  MEANS    OF    DIAGNOSIS. 

observed.  Her  evidence  leads  us  to  suspect  some  special  disorder, 
and  then  we  proceed  thus: — 

5th.  Direct  questions  are  put  with  the  intent  of  testing  the  cor- 
rectness of  the  suspicion  which  the  jjatient's  story  has  excited. 

6th.  Physical  means  are  brought  to  the  corroboration  of  the 
diagnosis  by  rational  ones. 

Forms,  either  written  or  printed,  such  as  that  which  follows, 
will  not  only  save  a  vast  deal  of  time  and  trouble,  but  give  uni- 
formity to  histories  taken,  so  that  after  a  number  of  them  have 
been  accumulated  they  may  be  collated  with  reference  to  special 
points,  or  preserved  for  personal  reference  or  publication. 

Case,  No. Date, 

Name _ __ Age _       _ Married? 

No.  of  children No.  of  abortions Time  since  last 

pregnancy -_     Age  at  which  menstruation  appeared 

Duration  of  present  illness Sj'mptoms  during  its  course 


Supposed  cause 


Present  condition  as  regards 

(  Regularity. 

Menstruation,  J  Amount 

I  Pain 


i  Character 
Amount _. 
Constancy 


Pain,                   i  Locality... 
(  Degree 


Locomotion 

Other  symptoms 

(  By  touch 

Physical  signs,  j  By  speculum. 

'  By  probe 

Diagnosis 

Treatment 


MANAGEMENT    OF    PATIENT    DURING    EXAMINATION.      59 

It  will  be  observed  that  I  have  not  enumerated  the  various 
rational  sio-ns  generally  attendant  upon  uterine  aflections,  but 
merely  the  means  for  drawing  them  forth.  Their  special  mention 
will  be  reserved  for  the  study  of  particular  affections.  If  the  evi- 
dence elicited  leaves  any  of  the  pelvic  viscera  under  suspicion,  this 
is  verified  or  removed  by  means  which  are  more  positive  and  reliable 
from  the  fact  that  they  address  our  senses. 

It  will  further  be  seen  that  the  headings  of  my  table  are  not 
numerous,  nor  the  table  itself  lengthy  or  exhaustive.  My  belief  is 
that  the  chief  reason  why  such  tables  are  not  more  generally  em- 
ployed is  that  they  are  so  long  and  so  filled  with  non-essential  items 
as  to  become  tedious  and  impracticable.  This  table  is  that  which 
I  employ  in  daily  practice.  I  find  that  when  filled  out  it  gives 
all  the  salient  points  in  my  cases  and  these  are  all  that  I  desire 
ordinarily  to  preserve. 

Management  of  Patient  during  Physical  Examination. — 
Before  commencing  the  consideration  of  physical  signs,  I  shall 
make  a  few  remarks  upon  a  subject  of  gi*eat  importance  in  this 
connection,  namely,  the  management  of  the  patient  during  the 
examination.  As  Dr.  Sims  has  taught  us,  she  sliould  never,  unless 
it  be  impossible  to  do  otherwise,  be  examined  upon  a  bed  or  sofa, 
but  upon  a  table  covered  with  a  blanket,  shawl,  or  rug  of  some 
kind,  and  provided  with  a  small  pillow.  The  facility  thus  given 
for  thorough  investigation  is  very  great,  and  the  avoidance  of  the 
sinking  of  the  body  into  the  soft  bed  repays  most  fully  the  extra 
trouble  w^liich  it  causes  to  make  the  change.  It  may  be  said  that 
mau}^  ladies  will  strongly  object  to  the  exposure  incident  to  getting 
upon  a  table.  This  is  not  so ;  a  little  persuasion  will  overcome 
such  objections  at  once,  and  the  increased  exposure  is  in  reality 
imaginary,  for  the  table  is  to  all  intents  a  bed,  and  a  sheet  for 
covering  the  person  gives  all  desirable  protection.  Should  it  be 
necessary  to  employ  a  bed,  the  leaf  of  a  dining-table  or  a  wide 
board  should  be  slipped  across  the  mattress  under  the  upper  sheet 
and  covering,  and  a  hard  surface  will  thus  be  presented  for  the 
patient  to  lie  upon,  which  will  obviate,  in  great  degree,  the  objec- 
tions to  the  bed  otherwise  arranged. 

The  patient  should  always  lie  upon  her  back  in  a  first  examina- 
tion, with  the  clothing  loose  around  the  waist,  the  knees  drawn  up 
and  the  abdominal  walls  relaxed.  A  sheet  should  be  spread  over 
her  so  as  to  conceal  the  entire  person.  The  table  having  been  pre- 
viously turned  to  a  window  admitting  a  strong  light,  a  chair  should 


go  MEANS    OF    DIAGNOSIS. 

'a 

be  placed  at  its  foot  for  the  examiner,  and  at  the  right  side  of  it 
another,  iqion  which  has  been  arranged  a  basin  of  warm  water, 
soap,  and  a  towel. 

I 

Means  of  Physical  Diagnosis.  * 

I  shall  enumerate  and  consider  these  in  the  order  in  which  they 
will  generally  be  employed  in  a  case  requiring  the  aid  of  all  of  them 
for  its  elucidation: — 

1.  Anesthesia. 

2.  Vaginal  touch. 

3.  Conjoined  manipulation. 

4.  Abdominal  palpation. 
6.  Abdominal  palpation  conjoined  with  use  of  the  sound. 

6.  Ins[)ection. 

7.  Eectal  touch. 

8.  Vesico-rectal  exploration. 

9.  The  speculum. 

10.  The  uterine  probe  and  sound. 

11.  Tents.  y 

12.  The  exploring  needle.  ! 

13.  The  aspirator.  ' 

14.  Tlie  microscope. 

15.  Auscultation  and  percussion. 

ANiESTHESiA. — Tliis  sliould  not  be  resorted  to  unless  there  be 
some  special  indication  for  it.  Should  the  patient  be  intractable, 
delirious,  or  a  malingerer ;  should  the  investigation  involve  mucha 
severe  pain  ;  or  should  there  be  some  tonic  spasm  of  the  muscles  as 
an  element  of  the  disease,  as  is  the  case  in  spurious  pregnancy  and 
phantom  tumors,  it  afibrds  an  aid  to  diagnosis  of  great  value,  and 
should  never  be  neglected.  When  we  are  forced  to  examine  a 
virgin  who  is  very  sensitive,  and  opposed  to  the  investigation, 
it  is  sometimes  advisable,  for  without  it  a  diagnosis  is  frequently 
impracticable. 

Vaginal  Touch. — This,  which  will  be  the  first  explorative  mea- 
sure to  which  the  examiner  will  resort,  constitutes  one  of  the  most 
important  at  his  command.  It  will  reveal  much  or  little,  as  it  is 
practised  slowly  and  thoughtfully,  or  hastily  and  as  a  matter  of 
routine.  In  making  it  the  index  finger  of  either  hand  may  be  era- 
ployed,  and  when  it  is  desirable  to  reach  as  far  up  the  pelvis  as 
possible,  the  index  and  middle  fingers  may  be  used.     During  this 


VAGINAL    TOUCH.  61 

examination  the  patient  should  invariably  be  laid  upon  the  back, 
with  the  legs  flexed  and  the  buttocks  very  near  the  edge  of  the 
table.  The  observance  of  this  position  is  of  great  importance,  as 
vao-inal  touch  should  in  every  case  be  combined  with  abdominal 
jialpation,  to  which  union  the  name  of  conjoined  manipulation  or 
bimanual  palpation,  has  been  applied. 

The  index  finger  of  one  hand,  being  introduced  into  the  vagina, 
the  other  fingers  being  flexed  into  the  palm  and  the  thumb  laid 
upon  them,  passes  directly  to  the  cervix  uteri,  assuring  the  inves- 
tigator, as  it  goes,  of  the  perviousness  of  the  vaginal  canal.  Upon 
reaching  the  os,  this  part  is  carefully  examined  with  reference  to 
size,  consistency  of  lips,  and  character  of  discharge;  a  patulous  os, 
with  soft,  velvety  sides  covered  by  a  glutinous  secretion,  admonish- 
ing liim  of  the  existence  of  inflammation  of  the  os  and  cervical 
canal.  The  cervix  should  then  be  examined  with  reference  to  loca- 
tion, size,  and  density.  This  being  done,  the  finger  should  be  slid 
along  its  posterior  surface  into  the  recto-uterine  space,  and  the 
presence  of  any  hardness  or  tumefaction  there  be  noted.  Should 
such  be  found,  it  will  probably  be  due  to  one  of  these  causes:  retro- 
flexion or  retroversion  of  the  uterus,  uterine  enlargement,  a  fibrous 
tumor,  scybal?e  in  the  rectum,  inflammatory  products,  the  result  of 
})eri-uterine  cellulitis  or  peritonitis,  a  prolapsed  ovary  or  ovarian 
tumor,  or  an  hematocele.  Should  no  tumor  be  discovered,  but  the 
line  of  resistance  given  to  the  finger  be  found  to  disappear  at  the 
vaginal  junction  with  the  uterus,  it  may  be  inferred  with  moderate 
certainty  that  at  this  point  none  of  the  above-mentioned  conditions 
exist. 

This  space  being  explored,  the  finger  should  then  be  passed  ante- 
riorly, and  swept  upward  and  forward  along  the  base  of  the  bladder 
toward  the  symphysis  pubis.  Any  hardness  discovered  here  will 
probably  be  due  to  anteflexion  or  anteversion  of  the  uterus,  a  fibrous 
tumor,  stone  in  the  bladder,  uterine  enlargement,  or  possibly  cellu- 
litis. 

The  state  of  the  ovaries  should  then  be  tested  by  lateral  pres- 
sure, and  the  condition  of  the  pelvic  areolar  tissue  and  walls  by 
firm  pressure  in  all  directions. 

In  certain  rare  and  obscure  cases,  such,  for  example,  as  those  in 
which  a  diagnosis  of  large  tumors  in  the  vagina  is  very  difficult,  it 
becomes  necesssary  to  introduce  the  whole  hand  into  the  vagina. 
This  procedure,  which  is  usually  resorted  to  while  the  patient  is 
anaesthetized,  should  be  practised  with  the  greatest  caution.     Other- 


62 


MEANS    OF    DIAGNOSIS. 


wise  injury  may  be  done  to  the  parts  about  the  vulva,  and  a  large 
and  carelessly  managed  hand  may  produce  rui)ture  of  the  vagina. 

One  manoeuvre  by  which  touch  of  the  parts  lying  closely  in 
contact  with  Douglas's  cul-de-sac  is  much  facilitated  still  remains  to 
be  mentioned.  Where  small  tumors  exist  behind  and  disconnected 
with  the  uterus,  or  where  enlarged  and  prolapsed  ovaries  are  to  be 
sought  for  and  examined,  an  excellent  result  is  often  obtained  by 
placing  the  patient  in  Sims's  left  lateral  position,  and  passing  the 
index  and  middle  fingers  of  the  right  hand  as  high  up  as  possible, 
their  palmar  surfaces  looking  towards  the  posterior  wall  of  the 
vagina.  By  this  method  I  have  repeatedly  detected  enlarged  and 
slightly  displaced  ovaries  which  in  the  dorsal  decubitus  had  entirely 
escaped  observation. 


Conjoined  Manipulation,  or  Bimanual  Palpation. — As  the  pre- 
ceding examination  consists  in  touching  organs  above  the  pelvic 
roof  for  the  most  part,  and  which  are  generally  quite  nioval)le,  it  is 
evident  that  its  results  are  diminished  by  ascent  of  these  parts  as 
they  are  pressed  ujion.  To  bring  them  more  fully  within  the  reach 
of  the  finger  in  the  vagina,  and  to  prevent  their  retreat,  abdominal 
palpation    should    invariably   be  combined    with   vaginal   touch. 

Fiff.  2. 


Practice  of  conjoined  maniimlation.     (Sims.) 

While  the  latter  is  being  performed  by  the  index  finger  of  one 
hand,  the  other  hand  should  be  placed  on  the  abdomen,  and  by  it 
the  uterus  be  made  to  descend,  so  that  even  its  upper  parts  may 
become  accessible.     This  will   enable  the  examiner  to  sweep  the 


ABDOMINAL    PALPATION.  63 

fincrer  in  the  vagina  over  the  posterior,  anterior,  and  lateral  surfaces 
of  the  organ,  and  detect  the  presence  of  any  enlargement,  sensitive- 
ness, or  abnormal  growth  there.     Fig.  2  represents  this. 

But  not  only  should  the  walls  of  the  uterus  be  thus  explored:  the 
volume,  shape,  sensitiveness,  and  regularity  of  surface  of  this  organ, 
as  well  as  of  the  ovaries,  the  broad  ligaments,  anterior  vaginal  wall, 
and  bladder,  should  likewise  be  ascertained.  To  accomplish  this 
with  reference  to  the  uterus,  let  the  finger  in  the  vagina  be  placed 
under  it — anterior  to  the  cervix  if  it  be  in  normal  position  or  ante- 
Hexed,  posterior  to  it  if  it  be  retroflexed — and  the  organ  will  be 
distinctly  felt  resting  between  it  and  the  fingers  which  depress  the 
abdominal  walL  By  the  same  method  the  other  parts  mentioned 
should  be  examined.  Conjoined  manipulation  is  of  great  import- 
ance; indeed  no  examination  can  be  considered  complete  without  it. 
By  a  neglect  of  this  seerningh'  trifling  [)recaution  I  have  known  the 
existence  of  large  tumors,  and  even  of  pregnancy  quite  advanced, 
entirely  ignored.  A  short  time  ago  a  physician  sent  to  me  from  a 
distance  a  case  which  he  supjiosed  to  be  one  of  prolapsus  uteri,  from 
the  fact  that  the  uterus  was  low  in  the  pelvis,  never  suspecting  for 
a  moment  the  existence  of  two  fibrous  tumors,  each  the  size  of  a 
foetal  head,  which  depressed  the  displaced  organ. 

Abdominal  Palpation. — The  practice  of  bimanual  palpation  will 
have  assured  the  investigator  of  the  presence  of  any  tumors  which 
may  exist  in  the  pelvis.  Should  such  have  been  discovered,  a 
further  examination  will,  of  course,  at  once  be  entered  up(Mi  to 
ascertain  their  size,  shape,  attachments,  and  contents.  In  this  ex- 
ploration both  hands  are  employed  externally,  and  by  them  firm 
pressure  is  made  and  the  abdominal  walls  depressed,  so  that  by 
grasping  the  masses  their  characters  may  be  appreciated.  By  this 
means  the  diagnostician  decides  as  to  the  solidity  or  fluidity  of 
tumors,  their  sensitiveness  to  pressure,  the  presence  of  foetal  move- 
ments, and  other  points  of  equal   importance. 

Abdominal  Palpation  conjoined  with  the  use  of  the  Sound. — I 
shall  very  soon  speak  of  the  uterine  sound  in  relation  to  its  ordinary 
and  more  legitimate  functions.  Here  I  allude  to  it  only  as  a  means 
of  rotating  the  uterus  in  the  pelvis  in  order  that  the  hand  pressed 
upon  the  abdomen  may  separate  it  from  enlargements  in  the 
abdomen.  This  method  of  investigation  is  of  so  great  value,  and 
appears  to  me  so  little  appreciated  and  so  rarely  practised,  that  I 
wish  to  draw  especial  attention  to  it.     Let  us  suppose  that  a  tumor 


g4  MEANS    OF    DIAGNOSIS. 

occupies  the  pelvis  or  lower  portion  of  the  abdomen,  and  it  be 
desired  to  determine  how  close  a  relation  exists  between  it  and  the 
uterus.  The  sound  being  passed  to  the  fundus,  the  patient  lying 
upon  the  back,  it  is  made  to  rotate  the  uterus.  The  left  hand,  which 
is  uiioccui)ied,  is  now  placed  on  the  abdomen,  so  as  to  become  cogni- 
zant of  movements  in  the  uterus  and  tumor.  If  both  move  equally, 
their  connection  is  intimate;  if  the  uterus  move  freely  and  the 
tumor  but  little,  it  is  less  marked  ;  while  if  the  tumor  remains 
stationary  during  rotation  of  the  uterus  there  is  probably  no  con- 
nection, or  one  only  by  lengthy  bonds  of  union. 

Again,  in  cases  where  palpation  and  conjoined  manipulation  fail 
to  map  out  the  position  of  the  uterus  on  account  of  obscure  pelvic 
tumors  or  great  obesity  of  the  woman,  lifting  the  organ  by  the 
sound  and  rotating  it  under  the  palm  laid  upon  the  abdomen,  is  a 
valuable  resource. 

Lastly,  in  cases  of  supposed  fibrous  polypus  where  one  fears 
to  operate  lest  an  inverted  uterus  may  have  misled  him,  although 
the  passage  of  the  sound  alone  makes  him  almost  sure  as  to  diag- 
nosis, it  gives  confidence  to  feel  the  uterine  body  rolling  under 
the  hand  laid  over  the  abdomen,  for  it  is  not  an  unheard-of  occur- 
rence for  tlie  sound  to  pass  through  the  uterine  walls  and  enter  the 
peritoneum. 

I  would  urge  this  procedure,  as  a  rule,  in  the  examination  of 
abdominal  and  pelvic  tumors.  Indeed,  in  a  large  number  of  such 
cases,  a  neglect  of  it  will  allow  of  errors  in  diagnosis,  which,  by  its 
adoption,  might  have  been  avoided. 

Inspection. — A  great  deal  may  be  learned  from  the  inspection  of 
diseased  growths  about  the  vulva,  or  ostium  vaginae,  and  of  tumors 
in  the  vagina,  which  may  be  drawn  down  between  the  labia,  and 
valuable  information  may  be  gained  concerning  abdominal  enlarge- 
ments by  this  means.  For  example,  the  shape  of  an  ovarian  cyst 
is  globular  and  protuberant,  while  that  of  an  abdomen  afifected  by 
ascites  is  flat  and  bulging  at  the  sides ;  the  form  of  a  mono-cyst 
is  usually  globular,  while  that  of  a  poly-cyst  is  commonly  irregular; 
the  development  of  a  pregnant  uterus  is  regular  and  symmetrical ; 
that  of  a  solid  tumor  of  the  uterus  generally  irregular  and  unsym- 
metrical. 

Rectal  Touch. — Should  anything  have  been  discovered  upon 
either  uterine  wall  to  make  further  light  upon  the  state  of  these 
parts   desirable,  or  should  symptoms  have  presented  themselves 


' 


KECTAL    TOUCH.  65 

which  excite  suspicion  of  the  presence  of  some  morbid  growth,  the 
index  finger  of  one  hand  should  be  carried  far  up  into  the  rectum, 
and,  if  necessary  to  enable  it  to  reach  the  posterior  uterine  wall,  a 
tenaculum  should  be  fixed  in  the  cervix,  and  by  gentle  traction 
the  organ  drawn  down.  Generally,  however,  sufficient  depression 
will  be  accomplished  by  firm  pressure  over  the  hypogastrium  with 
the  other  hand,  the  tips  of  the  fingers  pressing  the  uterus  towards 
the  floor  of  the  pelvis;  or  both  of  these  means  may  be  combined 
by  bringing  to  our  aid  the  hand  of  an  assistant.  Those  who  have 
not  employed  this  method  systematically  must  have  a  faint  idea  of 
the  great  facility  which  it  gives  for  exploration  of  the  lower  por- 
tion of  the  posterior  wall  and  recto-uterine  space. 

Valuable  as  is  this  method  of  exploring  by  the  rectum,  it  has 
been  of  late  greatly  improved  upon  by  Prof.  Simon,  of  Heidelberg, 
who  has  systematized  the  plan  of  passing  the  entire  hand  into  the 
intestine  and  introducing  the  forearm  as  far  as  its  middle.  By 
j  this  means  a  positive  diagnosis  maj'  be  made  of  many  diseased 
I  states  of  the  uterus,  ovaries,  rectum,  and  sometimes  even  of  the 
kidnej-s.  By  it  the  examiner  is  enabled  to  hold  the  ovaries  be- 
tween the  thumb  and  finger  and  appreciate  their  size,  consistence, 
and  smoothness;  to  discover  tumors  of  the  uterus  no  larger  than  a 
cherry  ;  to  ascertain  the  length  of  the  pedicle  of  an  ovarian  cyst, 
and  the  freedom  from  attachments  of  the  cyst  itself;  and  in  a  case 
of  renal  cyst,  to  learn  that  the  tumor  has  no  connection  with  the 
pelvic  organs. 

This  method  may  be  combined  with  abdominal  palpation,  and 
where  its  complete  development  is  not  called  for,  may  be  modified 
by  limiting  it  to  the  introduction  of  the  hand,  with  the  exception 
of  the  thumb. 

There  can  be  no  question  as  to  the  great  value  of  Simon's  method. 
It  will  in  the  future  serve  to  throw  a  flood  of  light  upon  many 
cases  which  now  prove  exceedingly  obscure  in  spite  of  all  our 
eflbrts.  My  experience  with  it,  thus  far,  makes  me  very  sanguine 
as  to  its  future,  not  only  as  a  means  of  diagnosis,  but  of  treatment 
in  certain  forms  of  posterior  displacement  of  the  uterus. 

Simon's  method  is  thus  jiut  into  practice: — 

1st.  The  patient  is  anaesthetized  and  jJaced  in  an  exaggerated 
lithotomy  position  ;  the  knees  being  thrown  upwards  so  as  to  flex 
the  thighs  sharply. 

2d.  The  sphincter  ani  is  thoroughly  stretched  and  first  the  fingers, 
and  then  the  hand  cautiously  introduced.  In  certain  very  rare 
cases  an   incision,  involving  the  sphincter,  is  made  through  the 


QQ  MEANS    OF    DIAGNOSIS. 

posterior  raphe  of  the  anus.     For  diagnostic  purposes  this  is  very 
seldom  required. 

3d.  The  lingers  are  then  separated  and  a  careful  examination  of 

the  pelvic  organs  is  made. 

4th.  Should  it  be  found  necessary  to  invade  the  parts  above  the 
level  of  the  sacrum,  three  or  four  fingers  are  introduced  into  the 
sigmoid  flexure,  so  that  we  may  "  reach  above  the  umbilicus  with- 
out in  the  least  injuring  the  intestines  or  peritoneum,  and  the 
upper  portion  of  the  rectum  and  sigmoid  flexure  being  extremely 
movable,  can  palpate  the  whole  abdomen  as  far  as  the  lower  edge 
of  the  kidney." 

The  procedure  requires  caution.  Violence  and  force  must  be 
avoided,  and  no  attempt  must  be  made  to  introduce  more  than  three 
or  four  fingers  into  the  sigmoid  flexure. 

Should  any  substance  lie  in  the  recto-vaginal  space,  its  character 
may  be  accurately  appreciated  by  what  has  been  styled,  by  Dr.  Tilt, 
the  "  double  touch,"  which  consists  in  introducing  the  index  finger 
into  the  rectum  and  the  thumb  into  the  vagina,  and  then  approxi- 
mating them.  Or  the  index  of  one  hand  may  be  introduced  into 
the  vagina  and  that  of  the  other  into  the  rectum. 

Yesico-rectal  Exploration. — This  consists  in  passing  a  catheter 
or  sound  into  the  bladder,  and  pressing  it  towards  the  index  finger 
in  the  rectum.  Its  scope  is  not  extensive,  but  for  some  purposes 
no  other  method  answers  the  same  end,  as,  for  example,  for  the 
following: — 

Appreciating  the  size  of  the  uterus  in  very  fat  women; 

Detecting  absence  of  the  uterus; 

Diflerentiating  inversion  from  polypus. 
The  only  difierence  between  this  method  and  conjoined  manip- 
ulation consists  in  the  attempt  to  grasp  the  uterus  between  the 
finger  and  sound  instead  of  between  the  fino^ers  of  the  two  hands. 
Who  the  originator  of  this  ingenious  method  is  I  cannot  say.  By 
Mr.  C.  F.  Weiss  it  is  attributed  to  Malgaigue. 

The  Speculum. — This  is  by  no  means  our  most  valuable  diag- 
nostic resource.  Too  great  a  reliance  upon  it  as  such  is  calculated 
to  diminish  the  physician's  powers  for  arriving  at  a  correct  conclu- 
sion in  obscure  cases.  Unquestionably  the  greatest  benefits  derived 
from  the  speculum  demonstrate  theniselves  in  the  therapeutic 
department  of  this  subject.  As  a  diagnostic  means  it  is  inferior  to 
vaginal  and  rectal  touch  combined  with  abdominal  palpation,  and 


THE    SPECULUM. 


67 


chiefly  aids  us  in  this  field  by  opening  the  way  to  the  proper  use 
of  the  uterine  probe,  which  constitutes  one  of  the  most  reliable 
methods  at  our  command  for  appreciating  the  condition  of  the 
cavity  of  the  uterus. 

All  vaginal  specula  may  be  classified  under  two  heads,  cylindrical 
and  valvular.  Of  the  first  variety  cylinders  of  metal,  porcelain, 
ivorj^,  and  wood  are  in  general  use.  None  of  these  compare  in 
elegance,  cleanliness,  and  utility  with  that  of  Dr.  Fergusson,  of 
London,  which  consists  of  a  tube  of  glass  coated  with  quicksilver, 
and  covered  by  India-rubber,  which  is  thoroughly  varnished.  This 
instrument  is  represented  in  Fig,  3. 

Fig.  3. 


Fergusson's  speculum. 

Objections  which  attach  to  all  cylindrical  instruments  are  the 
following:  to  suit  all  cases  they  must  be  from  five  to  six  inches 
long,  which  renders  probing  the  uterus  through  them  impossible, 
and  prevents  applications  from  being  carried  to  the  fundus ;  it  is 
not  possible  to  examine  through  them  by  touch ;  in  anteversion 
it  is  difficult  to  get  the  cervix 
into  the  field.     The  instrument  Fig.  4. 

represented  in  Fig.  4  obviates 
many  of  these  difficulties  by  ac- 
commodating itself  to  the  length 
of  every  vagina,  so  that  the 
shoulders  come  just  between  the 
labia. 

It  consists  of  two  thin  metallic 
tubes,  one  of  which  slides  within  the  other.  To  the  inner  tube  are 
attached,  at  the  mouth,  wings  which  sustain  the  labia,  and  the 
outer  tube  ends  in  a  tip  which  is  either  straight  or  curved.  It  is 
called  the  "  telescopic  speculum,"  from  its  mechanism,  and  mea- 
sures, when  not  extended,  along  its  shorter  side  two  and  a  half 
inches,  along  the  opposite,  three.  "When  extended,  it  is  as  long  as 
the  ordinary  cylindrical  specula.  On  both  surfaces,  upper  and 
lower,  are  two  fenestrse,  which  admit  of  elevating  or  depressing  the 


a  ne/uAUM'CO. 


Thomas's  telescopic  speculum. 


68 


MEANS    OF    DIAGNOSIS. 


probe  in  cases  where  flexion  or  version  exists,  and  its  handle  must 
be  much  lowered.  A  downward  curve  may  with  advantage  be 
given  to  the  longer  lip.  This  curve  looks  at  first  both  odd  and 
useless;  but  ui3on  experiment  it  will  be  found  to  answer  a  very 
useful  purpose.  In  cases  where  the  uterus  is  normal  in  position  it 
will  not  de[)ress  the  cervix  too  much,  while  by  turning  it  up  when 
this  part  lies  imbedded  in  the  hollow  of  the  sacrum  the  examiner 
will  be  enabled  to  lift  it  and  engage  it  in  the  Held  of  the  speculum. 
When  fully  introduced  the  wings  at  the  mouth  of  the  instrument 
support  the  labia,  and  thus  no  superfluous  portion  extends  beyond 
the  vulva. 

Of  valvular  specula  the  bivalve  of  Ricord,  the  trivalve  of  Segalas, 
and  the  quadrivalve  of  Charri^re  have  long  been  popular.     No  in- 

Fia:.  5. 


Cusco's  Speculum. 

strument  of  this  variety  with  which  I  am  acquainted   equals  that 
of  M.  Cusco,  Fig.  5.     It  is  compact,  easily  introduced,  and  shows 

the  cervix  very  clearly. 


I 


Fig.  6. 


Neugebauer's  Speculum, 


Of  all  the  specula  thus  far 
mentioned  I  have  spoken 
from  personal  knowledge. 
The  next  I  show  upon 
faith  alone.  It  is  the 
speculum  of  Prof.  ]!^euge- 
bauer,  of  Warsaw,  which  is 
so  highly  commended  by 
some  of  the  most  eminent 
gynecologists  of  Great  Bri- 
tain that  I  bring  it  before 
the  reader  upon  their  au- 


THE    SPECULUM. 


69 


thoritj^  The  diagram  here  exhibited  shows  this  instrument  some- 
what modified  by  Dr.  Barnes,  of  London,  and  as  presented  by  him 
before  the  London  Obstetrical  Society. 

All  valvular  specula,  however,  present  these  great  disadvantages. 
It  is  difficult  to  avoid  ja'olapse  of  the  vaginal  walls  between  their 
branches,  and  in  removing  the  instrument  these  are  liable  to  be 
{lainfully  pinched.  If,  upon  introducing  and  expanding  their 
branches,  the  os  uteri  is  exposed,  all  goes  well;  but  if  it  is  not  in 
the  field,  these  instruments  are  awkward  and  unwieldy  in  over- 
coming the  difficulty;  indeed,  in  many  cases,  the  speculum  must 
be  withdrawn  and  reintroduced  to  accomplish  the  result.  They 
have  one  great  advantage  over  the  cylindrical  specula,  namely, 
their  introduction  is  attended  by  much  less  pain.  Should  the  case 
be  one  of  a  multijjara,  a  cylinder  may  be  introduced  without  pain, 
but  in  a  nullipara,  or  virgin,  this  is  often  caused. 

Like  the  cylindrical,  the  valvular  specula  in  general  use  do  not 
as  a  rule  admit  of  probing  the  uterus  and  making  applications  to 
the  fundus.     I  do  not  den}^  that  in  some 
cases  it  is  possible,  nor  that  by  perseverance  Fig.  7. 

a  skilful  operator  may  succeed  in  eftecting 
these  objects  in  many  instances,  but  it  is 
usually  so  difficult  that  the  general  practi- 
tioner will  not  find  such  specula  available 
for  these  ends. 


Fig-.  8. 


G,  /  lEMANN  &rc 

Sims's  depressor. 


Sims's  speculum. 


Sims's  speculum,  Fig.  7,  which  is  in  re- 
ality a  bivalve,  obviates  all  these  difficulties 
in  the  most  complete  and  satisfactory  man- 
ner. In  ex[)0sing  the  uterus  it  develops  a 
jtrinciple  not  brought  into  action  by  any 
otlier  variety,  the  dilatation  of  the  vaginal  canal  by  air,  which 
enters  on  account  of  the  position  of  the  patient  and  gravitation  of 
the  pelvic  and  abdominal  viscera.  I  have  stated  that  this  instru- 
ment is  a  bivalve  speculum ;  the  upper  valve  is  constituted  by  the 
blade  of  the  speculum  itself  and  the  lower  by  the  depressor,  repre- 
sented in  Fig.  8,  which  acts  upon  the  anterior  wall. 

The  facility  which  Sims's  instrument  gives  for  exploration  and 


70  MEANS    OF    DIAGNOSIS. 

treatment  is  very  great,  so  great,  I  think,  that  the  practitioner  de- 
votino-  himself  to  gynecology  who  does  not  avail  himself  of  it,  loses 
as  great  an  advantage  as  the  auscultator  would  forego  in  not  bring- 
ino-  to  his  aid  the  double  stethoscope  of  Camraan.  But  unfortu- 
nately this  instrument  presents  such  disadvantages  that  it  can  never 
come  into  general  use.  In  the  hands  of  those  attending  a  sufficient 
number  of  cases  of  uterine  disease  to  give  them  skill  in  manipula- 
tion and  opportunity  for  thoroughly  familiarizing  themselves  with 
it,  it  will  always  fill  a  large  place,  but  in  general  practice  it  will  not 
do  so.  It  cannot  be  employed  without  an  assistant,  and  not  only 
80,  a  skilled  assistant  is  necessary  for  it  to  be  of  real  value.  This 
fact  has  incited  many  to  alter  Dr.  Sims's  original  model  so  as  to 
combine  its  advantages  in  instruments  free  from  the  objections 
which  have  been  mentioned. 

A  few  of  these,  for  their  number  seems  destined  to  surpass  that 
of  modifications  of  the  forceps,  I  lay  before  the  reader. 

When  the  posterior  vaginal  wall  is  lifted  by  Sims's  speculum, 
the  anterior  must  be  depressed  by  an  instrument  held  in  the  other 
hand.  Thus  both  hands  are  occupied,  and  the  operator  is  bereft  of 
power  to  proceed.  The  object  of  the  alteration  is  to  liberate  one 
hand  in  order  that  the  further  steps  of  the  examination  may  be 
proceeded  with. 

Dr.  ITott's  speculum  (Fig.  9)  does  this  by  depressing  the  anterior 

Fig.  9. 


Nott's  speculum  closed. 


vaginal  wall  by  two  short  arms.  These  at  the  same  time  keep  the 
blade  of  the  speculum  itself  in  place,  and  thus  either  one  or  both 
hands  are  free  for  making  applications  to  the  uterus,  probing  its 
cavity,  or  whatever  else  may  be  required. 


THE    SPECULUM. 


71 


The  speculum  of  Dr.  J.  B.  Hunter  (Fig.  10)  is  simply  Siras's 
sr)ecuium,  with  its  blades  bent  inwards  so  as  to  enable  the  exam- 
iner to  fix  it  in  a  support  which  is  attached  to  the  table  and  acts 
as  a  mechanical  assistant.  The  speculum  being  thus  fixed  keeps 
its  position  perfectly,  and  the  examiner  with  both  hands  free,  pro- 
ceeds in  his  investigation,  employing  the  depressor  as  when  an 
assistant  aids  him.  To  make  this  arrangement  effectual  some  prac- 
tice is  necessary,  but  with  that  it  will  prove  an  excellent  one. 


Fig.  10. 


Fig.  11. 


Hunter's  speculum. 


Thomas's  modification  of  Sims's 
speculum. 


The  instrument  represented  in  Fig.  11  clasps  the  sacrum  ;  one 
blade,  «,  the  speculum  itself,  being  placed  within  the  vagina,  and 
the  other,  on  the  outer  surface  of  the  sacrum.  Their  approxima- 
tion by  the  left  hand  elevates  the  posterior  vaginal  wall,  and  the 
handle  is  held  by  one  hand.  The  anterior  wall  is  then  depressed 
by  the  depressor,  and  thus  one  hand  is  left  free.  This  instrument 
appears  complicated  in  a  diagram,  but  in  reality  it  is  by  no  means 
so.  For  a  long  time  I  employed  it  without  the  sacral  piece.  Some 
even  now  prefer  it  thus,  though  the  fatigue  which  it  causes  to  the 
left  arm  in  lifting  the  posterior  vaginal  wall  and  perineum,  consti- 
tutes an  objection  to  it. 

Method  of  Introducing  Valvular  and  Cylindrical  Specula. — The 
patient  being  placed  in  position  on  the  back,  as  already  explained, 
and  the  speculum,  probe,  and  whatever  other  instruments  are  to 
be  employed,  laid  in  a  basin  of  warm  water  at  the  bedside,  the 
physician  seats  himself  in  a  chair,  or  if  a  low  bed  be  used  instead 
of  a  table,  kneels  or  sits  upon  a  stool.  The  finger  having  been 
thoroughly  lubricated  with  soap  is  passed  up,  and  the  location  of 


72 


MEANS    OF    DIAGNOSIS. 


the  cervix  ascertained.  The  speculum,  similarly  lubricated,  is  then 
passed  in  this  way;  if  the  cylindrical  instrument  be  used,  the  perine- 
um is  depressed  by  its  tip,  and  it  is  very  slowly  and  gently  inserted 
and  carried  to  the  cervix — should  one  of  the  valvular  varieties  be 
employed,  it  is  inserted  closed,  and  expanded  after  reaching  the 
cervix. 


Introduction  of  Sims' s  Speculum  and  its  Varieties. — In  this  method 
of  examination  the  element  which  commands  success  is  not  the  use 
of  the  instrument,  but  the  position  of  the  patient.  If  the  position 
reconmiended  by  Sims  be  attained,  exposure  of  the  cervix  will  be 
easy ;  if  a  similar,  but  not  identical  attitude  be  substituted,  the  ex- 
amination will  prove  entirely  unsatisfactory. 

The  object  of  the  position  is  to  allow  the  abdominal  viscera  and 
walls  to  gravitate,  so  as  to  draw  the  anterior  wall  of  the  vagina  for- 
wards, in  a  direction  opposite  to  that  impressed  upon  the  posterior 
A\'all  by  the  speculum.  To  accomplish  this  the  patient  must  be  not  on 
her  back,  nor  on  her  side,  but  in  a  position  between  the  two.  This 
is  well  represented  in  Fig.  12.     Tlie  left  arm  must  be  drawn  behind 

Fig.  12. 


Nurse  holding  Sims's  speculum.     (Sims.) 


the  patient  so  as  to  let  her  rest  on  the  left  side  of  the  chest,  and 
the  right  leg  be  so  flexed  as  to  let  the  right  knee  lie  iust  above  the 
left.  °  "^ 


THE    UTERINE    SOUND.  73 

When  the  patient  is  arranged,  tlie  correctness  of  the  posture 
may  be  tested  by  noting  that  the  lower  trochanter  is  not  just  op- 
posite the  u[tper,  but  nearer  to  the  examiner  by  two  or  three 
inches.  I  am  thus  particular  in  describing  this  position,  iirst, 
because  it  is  difficult  for  one  unaccustomed  to  its  employment  to 
place  his  patient  properly  in  it ;  and,  second,  because  upon  its 
pf;r/ec^  attainment  depends  the  successful  use  of  Sims's  speculum. 
The  patient  being  in  position,  the  speculum  is  introduced,  the  pos- 
terior vaginal  wall  elevated  by  it  and  the  anterior  depressed  by  the 
depressor,  Fig.  8,  held  in  the  other  hand,  or  by  the  mechanical  de- 
pressor represented  in  Fig.  11. 

The  Uterine  Sound. — This  most  valuable  diagnostic  means  was 
published  to  the  world  about  the  year  1843.  The  credit  of  its 
discovery  is  claimed  for  Simpson,  of  Edinburgh,  Huguier,  of  Paris, 
and  Kiwisch,  of  Prague.  These  practitioners  simultaneously  re- 
vived an  old  method  of  diagnosis  which  had  been  described  in 
modern  times  by  Lair,^  but  had  been  allowed  to  fall  into  oblivion. 
It  matters  little  to  which  of  them  belongs  the  credit  of  having  been 
the  first  to  conceive  the  idea  of  the  regeneration,  to  Dr.  Simpson 
certainly  belongs  that  of  having  forced  it  upon  the  attention  of  the 
profession  and  established  its  value  by  clinical  evidence. 
The  instruments  in  general  use  are  those  of  Simpson,  Valleix, 
j  Huguier,  and  Kiwisch,  which  resemble  each  other  closely  in  prin- 
'  ciple,  each  consisting  of  a  stiff  metal  rod  divided  into  half  inches 
and  bent  so  as  to  pass  in  the  axis  of  the  healthy  uterus.  The 
method  of  their  introduction  is  this:  the  index  finger  of  one  hand 
being  introduced  into  the  vagina  and  placed  against  the  cervix, 
the  sound  is  by  the  other  slid  upon  its  palmar  surface  to  the  os, 
passed  into  it,  and  by  depression  of  the  handle  gently  advanced  to 
the  fundus.  If  the  uterus  be  in  its  normal  position,  and  the  sound 
be  used  by  a  skilful  hand,  the  operation  is  not  difficult.  But  it  is 
not  healthy  uteri  which  we  are  generally  called  upon  to  explore. 
if  the  organ  be  displaced,  the  difficulties  and  dangers  attending 
the  employment  of  the  sound  are  considerable,  as  may  be  judged 
of  from  the  following  quotations: — 

BecquereP  says:  "But  its  employment  is  attended  with  such 
difficulty  that  it  requires  all  the  skill  of  an  adroit  and  experienced 

'  Samuel  Lair,  '•  Nouvelle  methode  de  traitemeat  des  ulcferes,  ulcerations  et  en- 
gorgement de  I'ut^rus,"  1828. 
^  Maladies  de  I'ut^rus. 


74  MEANS    OF    DIAGNOSIS. 

practitioner,  and  we  dread  seein<^  it  popularized  among  young 
physicians  of  little  skill  and  experience."  Nonat^  declares  that, 
"on  account  of  the  accidents  which  sounding  may  excite,  it  should 
only  be  resorted  to  with  great  caution  and  in  those  cases  where  its 
necessity  is  clearly  shown."  Scanzoni^  candidly  acknowledges 
that, "  in  the  first  place,  the  uterine  sound  is  by  no  means  so  harm- 
less as  has  been  asserted,"  and  then  goes  on  to  sum  up  the  evils 
which  may  result  from  it.  But  I  will  not  quote  more;  this  suf- 
fices to  show  how  the  difliculties  and  dangers  to  which  I  have 
alluded  are  regarded  by  some  of  the  best  authorities  of  our  day. 
The  facts  which  may  be  ascertained  by  the  sound  are  these: — 

1.  The  capacity  of  the  uterus. 

2.  The  existence  of  growths  within  it. 

3.  Deviations  of  the  course  of  its  canal. 

4.  Differentiation  of  displacements  from  uterine  tumors. 

5.  The  existence  of  endometritis. 

6.  The  mobility  of  the  uterus. 


i 


The  great  injportance  of  these  facts  with  reference  to  diagnosis 
is  evident,  and  one  would  suppose  that  an  instrument  revealing  so 
much  would  be  universally  employed.  Such,  however,  is  not  by 
any  means  the  case.  By  adepts  it  is  commonly  resorted  to,  but  in 
general  practice  will  be  found  many,  indeed  a  majority,  who  do 
not  employ  it  from  fear  of  its  results,  the  difficultj^  of  its  introduc- 
tion, and  uncertainty  as  to  its  revelations.  It  is  my  opinion  that 
no  case  of  uterine  disease  should  be  regarded  as  fully  investigated 
unless  the  cavity  of  the  uterus  be  probed.  Of  course  there  are, 
in  some  cases,  contra-indications  to  such  a  procedure,  but  where 
none  exist  it  should  be  considered  as  essential  to  a  thorough  ex- 
amination. This  remark  does  not  apply  to  the  sound  as  ordinarily 
employed,  but  to  the  jprohe  passed  through  Sims' s  speculum. 

Dr.  Sims  has  furnished  us  with  a  new  instrument  and  method 
for  prol)ing  the  uterus,  which  acts  upon  an  essentially  difterent  ' 
principle  from  that  formerly  employed,  and  makes  the  investiga- 
tion so  simple  and  void  of  danger,  that  I  strongly  recommend  its 
adoption.  In  practice  I  use  it  in  almost  every  case  which  I  ex- 
amine for  the  first  time,  and  never  have  I  done  injury  by  it  except 
in  two  cases  where  miscarriage  was  produced,  no  suspicion  of  preg- 
nancy being  entertained. 


Maladies  de  1' uterus.  2  Diseases  of  Females,  Am.  ed. 


THE    UTERINE    SOUND    AND    PROBE. 


75 


Fio*.  13  represents  the  sounds  of  Simpson  and  Sims,  for  the  pur- 
pose of  contrasting  them.  The  first  is  a  strong,  unyielding  staff', 
composed   of  German  silver, 

and  as  large  as  a  No.  3  cathe-  Fig.  13. 

ter. 

The  second  is  not  a  sound, 
but  a  [)robe,  only  a  little  larger 
than  the  ordinary  surgical 
probe,  composed  of  pure  silver 
or  copper,  and  perfectly  pli- 
able. 

Mode  of  Probing  the  Uterus. — 
While  the  woman  lies  on  her 
back,  the  examiner,  by  vagi- 
nal touch,  carefully  ascertains 
the  position  of  the  uterus,  by 
passing  his  finger,  first  into 
the  fornix  vaginae,  over  its 
posterior  face,  and  then  along 
the  base  of  the  bladder,  over 
its  anterior  wall.  This  gives 
him  a  definite  idea  of  the 
direction  of  the  canal  along 
which  he  is  to  pass  his  probe, 
and  without  it  he  should 
never  essay  the  procedure. 
The  speculum  is  then  intro- 
duced,  the  patient   retaining 

the  dorsal  decubitus  if  a  short  cylindrical  instrument  be  employed, 
and  being  turned  on  the  left  side  if  Sims's  or  one  of  its  varieties 
be  used.  The  examiner  then  takes  the  probe,  and  with  his  fingers 
gives  it  the  exact  curve  which  he  supposes  the  uterine  canal  to 
have,  and  gently  endeavors  to  pass  it  in.  Should  he  fail,  he  with- 
draws the  instrument,  alters  the  curve  slightly,  and  makes  other 
attempts  until  he  succeeds,  which  will  be  very  soon  if  he  has  used 
this  method  so  often  as  to  have  given  himself  experience.  Every 
effort  at  introduction  is  made  as  cautiously  as  if  the  probe  were  pass- 
ing into  the  larynx  instead  of  the  womb,  and  no  force  whatever  is 
exerted.  Success  is  attained  by  properly  curving  the  probe,  and  by 
ithat  alone.  Sometimes  the  inflection  given  to  it  must  be  the  are 
•of  a  small  circle;  at  others  a  sharp  angle;  sometimes  the  instru- 
iment  is  left  perfectly  straight;  in  fact  every  variety  of  direction 


Sounds  of  Simpson  and  Sims  compared. 


76  MEANS    OF    DIAGNOSIS.  » 

may  be  given  it.  In  a  certain  set  of  rare  cases,  even  a  spiral  twist 
is  required. 

Tims  employed,  the  uterine  probe  becomes  a  means  of  verifying 
a  diagnosis  which  has  been  made  by  touch,  and  is  certainly  safe, 
easy  of  introduction,  and  painless.  It  may  be  used  in  all  cases 
except  pregnancy,  doing  no  injury  even  in  endometritis,  so  gentle 
is  its  entrance  into  the  inflamed  cavity. 

No  one  can  dispute  the  fact  that  having  been  passed  it  performs 
the  chief  functions  of  the  sound,  proclaiming  the  course,  length, 
and  capacity  of  the  uterine  canal. 

There  are  two  things  required  of  the  uterine  sound  and  probe, 
which  none  of  those  instruments  which  I  have  shown  thoroughly 
and  satisfactorily  perform.  The  first  is  the  measurement  of  a  ute- 
rus very  much  enlarged  by  a  submucous  fibroid ;  the  second  the 
sej^arate  measurement  of  neck  and  body.  For  these  purposes  I  have 
had  constructed  a  very  simple  instrument,  which  is  shown  in  Fig. 
14.     It  consists  of  a  slender  rod  of  whalebone,  ending  in  a  knob 

Fig.  14. 


Thomas's  Elastic  Probe. 

the  size  of  a  buckshot.  The  entire  instrument  measures  eighteen 
inches,  of  which  four  are  given  to  the  handle  and  twelve  to  the 
shaft.  When  an  enlarged  uterus  containing  a  fibroid  is  to  be 
measured,  the  knob  is  gently  pushed  through  the  os  interiium  and 
upwards  to  the  fundus.  The  shaft  bends,  the  knob  does  no  in- 
jury to  the  uterine  walls,  and  the  measurement  is  obtained.  The 
length  of  the  cervical  and  uterine  cavities  may  be  obtained  in  two 
ways:  first,  the  knob  is  pushed  upwards  to  the  os  internum  until 
resistance  marks  the  end  of  the  canal ;  then  it  is  pushed  ni)wards 
to  the  fundus,  and  the  degree  of  penetration  noted,  and  the  mea- 
surement taken ;  second,  the  knob  is  carried  by  gentle  pressure 
through  the  os  internum  up  to  the  fundus,  and  the  measurement 
observed ;  then  it  is  drawn  down  to  the  os  internum,  and  the  dif- 
ference will  give  the  depth  of  each  cavity.  It  would  prove  some- 
what diflicult  to  cause  the  bulb  on  this  instrument  to  penetrate  the 
08  internum  of  a  healthy  uterus  ;  but  in  a  diseased  uterus,  which 
we  are  generally  called  upon  to  measure,  it  is  usually  easy.  I  have 
employed  this  simple  probe  so  constantly,  within  a  few  years  past, 
that  I  cannot  imagine  how  I  could  now  dispense  with  it. 


TENTS.  77 

Tents. — Before  the  time  of  Recamier,  the  cavity  of  the  uterus 
was  a  space  entirely  closed  to  investigation  and  local  therapeutics, 
unless  the  os  were  greatly  dilated  by  disease.  He  not  only  aspired 
to  an  accurate  knowledge  of  its  affections,  but  boldly  applied  his 
remedies  directly  to  the  diseased  surface:  and,  in  cases  of  intra- 
uterine granulations,  scraped  off  the  diseased  mucous  coat  with  the 
curette.  Even  to  him,  however,  the  diagnosis  of  diseases  within 
the  cavity,  when  the  os  was  closed,  was  an  impossibility,  and  for 
the  means  of  combating  this  difficulty  we  are  again  indebted  to  Dr. 
Simpson,  who,  in  1844,  placed  the  use  of  sponge-tents  among  the 
most  important  of  our  resources  for  diagnosis. 

The  object  for  which  they  are  employed  is  the  dilatation  of  the 
cervical  canal,  in  order  that  the  cavity  of  the  body  may  be  examined 
by  touch  or  sight,  and  that  treatment  may  be  applied  in  cases  of 
polypi,  granulations,  fibrous  tumors,  hydatids,  removal  of  the  pro- 
ducts of  conception,  etc. 

A  variety  of  substances  have  been  recommended  for  the  manu- 
facture of  tents,  only  two  of  which  have  come  into  general  use,  com- 
pressed sponge  and  the  laminaria  digitata,  or  sea-tangle. 

The  practitioner  should  no  more  think  of  preparing  his  own 
sponge-tents  than  his  extracts  or  tinctures.  They  are  now  made 
l)y  those  who  possess  much  more  skill  and  experience  than  himself, 
and  by  procuring  them  from  these  manufacturers  the  interests  of 
both  himself  and  his  patient  will  bo  subserved.^     They  should  he 

Fiff.  15. 


A  spotige-tent. 

steeped  in  a  solution  of  carbolic  acid  as  an  antiseptic,  and  may  be 
medicated  with  iodine,  zinc,  copper,  or  other  substances.  The  cord 
attached  to  a  tent  should  always  pass  through  it,  and  be  attached 
at  its  upper  extremity.     A  neglect  of  this  simple  precaution  has 

'  Tents  carefully  and  honestly  prepared  may  be  obtained  by  mail,  from  W.  J. 
Porter,  113  AVashinirton  Street,  Newark,  N.  J.,  as  well  as  from  the  instrument  makers 
of  this  city,  Boston,  and  Philadelphia. 


MEANS    OF    DIAGNOSIS. 


J 


repeatedly  allowed  the  tent  to  break  upon  its  removal,  and  one-half 
to  remain  in  the  cavity  of  the  body  of  the  uterus. 

Preparation  of  Sea-Tangle  Tents.— In  1862/ Dr.  Sloan,  of  Ayr, 
Scotland,  tirst  recommended  the  use  of  this  substance  for  dilating 
the  cervix  uteri.  The  laminaria  is  an  aquatic  plant  found  upon 
various  parts  of  the  Atlantic  coast  of  Europe  and  America.  That 
found  in  tlie  Bay  of  Fuudy,  I  am  informed  by  Messrs.  Tiemann  & 
Co.,  is  far  superior  to  any  other  with  which  they  have  experi- 
mented. This  plant,  when  saturated  with  moisture,  swells  to 
three  times  the  bulk  which  it  has  when  thoroughly  dried.  In  its 
moist  state  a  long  piece  of  it  is  perforated  at  both  extremities,  in 
order  that  it  may  l)e  hung  up  and  allowed  to  dry,  a  weight  being 
attached  to  the  lower  end  so  as  to  stretch  it  and  make  it  straight. 
When  dry,  this  is  cut  into  pieces  from  two  to  two  and  a  half  inches 
long  and  made  perfectly  smooth  and  round  by  a  knife,  a  piece  of 
glass,  or  sand-paper.  Tiemann  &  Co.  prepare  them  very  beautifully 
by  turning  in  a  lathe. 

Dr.  Greenhalgh,  of  London,  has  improved  these  tents  by  having 
them  perforated  from  one  extremity  to  the  other,  so  as  to  make 

them  tubular  instead  of  solid,  i 

^^'  ^^' Thus  pre[)ared  they  will  dilate 

much   more  rajiidly  and  com- 
pletely.    One    of    Dr.    Green- 
halgh's  tents  is  represented  in 
Fig.  16. 
A  „„„  .      ,  4.    .  The  advantages  of  these  tents 

A  sea-tangle  tent.  '^ 

over  those  made  of  sponge  con- 
sist in  their  creating  no  fetor,  and  presenting  no  animal  matter  for 
absorption.  Their  disadvantages  are  their  requiring  a  longer  time  \ 
for  exi)ansion,  their  being  kept  in  the  cervix  with  greater  diffi-  \ 
culty,  and  offering  a  harder  substance  to  the  walls  of  the  cavity  of 
the  uterus. 

The  late  Dr.  ITott,  who  experimented  extensively  with  them, 
arrived  at  conclusions  very  much  in  their  favor,  as  will  be  seen 
from  an  examination  of  his  deductions  which  I  here  place  before 
the  reader. 

"1st.  Where  moderate  dilatation  is  required,  the  laminaria  is  prefer- 
able to  the  sponge-tents. 

"2d.  If  placed  in  warm  water,  just  before  introduction,  for  a  few 

'  Glasgow  Med.  Jouni.,  Oct.  1862. 

ill 


I 


TENTS.  79 

minutes,  they  become  flexible,  coated  with  mucilage,  are  easily  curved  to 
suit  the  cervical  canal,  and  may  be  inserted  with  the  utmost  facility. 

"3d.  From  their  smootliness  and  softness  they  are  removed  without 
force,  and  produce  no  abrasion  or  irritation. 

"  4th.  They  may  be  medicated  with  morphia,  iodine,  or  anything  solu- 
ble in  water,  but  do  not  absorb  alcoholic  solutions  or  glycerine.  After 
being  so  charged,  they  may  be  dried  and  kept  for  use  an  indefinite  time. 

"  5th.  They  do  not  become  putrid,  and  therefore  poisonous,  as  do 
sponge-tents,  and  may  therefore  Ije  retained  twenty-four  hours  or  more 
with  impunity. 

"6th.  The  black,  ovoid  laminaria,  from  the  Bay  of  Fund}^,  is  much 
preferable  to  the  other  varieties  yet  brought  to  our  markets,  and  free 
from  the  objections  made  to  laminaria  by  some  writers. 

"  7th.  The  laminaria  will  be  found  of  great  benefit  in  obstructive  dys- 
menorrhea, if  introduced  a  few  daj^s  before  the  menstrual  period,  and 
also  in  cases  of  uterine  catarrh  connected  with  contracted  cervix;  they 
prepare  the  way  well,  too,  for  all  intra-uterine  medication.  In  either 
case,  if  softened  in  hot  water  before  introduction,  they  rarely  produce 
any  pain  or  irritation. 

"  8th.  It  is  better  to  insert  several  small  tents  than  one  large  one,  as 
the  small  ones  expand  more  rapidly  than  the  large  ones." 

The  last  point  here  mentioned  is  one  of  great  importance  in 
their  use,  and  for  its  recognition  we  are  indebted  to  Dr.  Kidd,  of 
Dublin.  He  thus  speaks  of  it:  "When  the  uterine  tissues  are  re- 
laxed by  hemorrhage,  a  fine  tent  can  be  passed  at  once  through  tliC 
whole  length  of  the  cervix  and  on  to  the  fundus,  and  by  a  little 
care  a  number  of  fine  tents  can  be  packed  alongside  of  one  another 
in  the  canal,  when  a  single  large  one,  though  not  nearly  of  the 
size  of  the  bundle  so  formed,  could  not  be  passed  at  all.  The  first 
tent  introduced  serves  as  a  guide  to  the  others,  and  when  they 
absorb  fluid  and  swell  out,  they  not  only  dilate  the  os  internum  as 
much  as  the  os  externum,  but  also  the  cavity  of  the  uterus  itself."^ 

Mode,  of  introducing  Tents. — If  the  uterus  be  low  in  the  pelvis 
and  its  neck  dilated,  a  tent  may  be  held  in  the  bite  of  any  pair  of 
uterine  dressing- forceps  and  slipped  in  without  the  speculum,  the 
woman  lying  on  the  back.  In  ordinary  cases  they  should  be  intro- 
d.uced  through  the  short  cylindrical,  or  one  of  the  varieties  of 
Sims's  speculum.  The  introduction  is  most  easily  accomplished 
with  the  last  in  all  cases,  and  in  some  it  can  only  be  eflfected  with 
it.     The  uterus  being  fixed  and  held  by  the  tenaculum.  Fig.  17, 

•  Dublin  Quarterly  Jour.,  Feb.  1869. 


80 


MEANS    OF    DIAGNOSIS. 


the  tent,  grasped  by  a  pair  of  mouse-tooth  forceps,  is  directed  in  i 
coincidence  with  the  axis  of  the  uterus,  as  ascertained  by  the  j 


Fig.  17. 


a.r/£,>/A/v/i/tco. 

Tenaculum  for  fixing  the  uterus. 


probe,  and  gently  pushed  through  the  cervix,  as  represented  in  i 

Fig.  18. 

Fig.  18. 


Introduction  of  a  tent.     (Sims.) 

Should  its  retention  be  doubtful,  a  mass  of  cotton  should  bei 
y tacked  against  it  so  as  to  keep  it  in  place,  and  the  woman   be  di- 
rected to  remain  in  bed  until  it  is  removed. 

Its  removal  is  accomplished,  through  the  speculum,  with  thei 
same  forceps  by  which  it  was  introduced,  in  from  twelve  to 
twenty-four  hours,  or  by  traction  upon  the  thread  attached  to  it. 

Dangers. — There  is  always  danger  in  dilating  the  cervix  byi 
tents,  though  it  is  by  no  means  so  great  as  to  make  one  hesitate  i 
in  employing  them,  for  tl)e  cases  which  demand  them  are  often 
urgent  ones,  and  they  serve  a  purpose  not  attainable  by  any  othen 
means.  It  is  much  to  be  regretted  that  practitioners  have  noti 
shown  more  alacrity  in  publishing  unfortunate  results  from  the* 
use  of  this  method  of  exploration  and  treatment.  Had  all  the* 
fatal  cases  which  have  resulted  from  accidents  due  to  tents' 
been  faithfully  recorded,  the  list  would  now  be  a  long  one,  and  it' 
would  be  greatly  lengthened  by  a  record  of  all  the  instances  in/ 


TENTS.  81 

which  tedious,  exhausting,  and  dangerous  disease  has  thus  been 
excited.  It  may  then  be  asked  whether  it  is  right  to  recommend 
a  method  accompanied  by  so  much  danger.  Tlie  same  line  of 
argument  applies  to  this  question,  which  does  to  so  many  similar 
ones  in  medicine.  Great  dangers  attend  the  use  of  anaesthetics, 
of  narcotics,  and  other  means  which  are  in  daily  use,  but  the  jpro- 
■portion  of  accidents  occurring  from  their  use  is  small  although  the 
aggregate  is  large ;  and  the  good  which  they  effect  is  so  great  that 
their  evils  must  be  condoned. 

In  my  own  practice  I  have  met  with  three  fatal  cases  resulting 
from  the  use  of  tents.  In  one  they  were  employed  to  remove  a  foetal 
shell  which  had  been  retained  for  two  months  and  was  destroying 
the  patient's  life  by  septicaemia  ;  in  the  second  and  third  the  cervix 
was  being  dilated  for  the  removal  of  fibrous  polypi,  the  hemorrhage 
from  which  had  greatly  exhausted  the  patients.  One  of  these 
women  died  of  tetanus,  one  from  peritonitis,  and  one  from  an  over- 
whelming and  sudden  attack  of  septicaemia. 

A  short  time  ago  I  was  called  in  consultation  to  the  bedside  of  a 
lady  who  was  dying  of  general  peritonitis,  which  had  arisen  one 
week  after  the  removal  of  a  sponge-tent  by  her  physician,  who 
was  a  most  careful  and  competent  practitioner.  Dr.  Braxton 
Ilicks  says,  "I  have  seen  a  case  end  fatally  where  there  had  been 
dilatation  a  week  previous ;  mental  shock  suddenly  lighting  up 
the  inflammation  and  extending  it  to  the  peritoneum."  Beside 
these  I  have  seen,  as  every  other  gynecologist  has,  who  has  enj- 
ployed  this  means  to  any  extent,  a  number  of  cases  in  which  the 
following  aiFections  have  been  excited  by  them  :  pelvic-peritonitis, 
peri-uterine  cellulitis,  septicaemia,  endometritis,  and  hematocele. 

This  is  the  record  of  my  own  practice,  and  my  observation  of 
that  of  many  of  my  friends  whose  results  I  have  an  opportunity  of 
seeing  exactly  agrees  with  it.  Let  it  be  remembered  that  many  of 
the  operations  of  gj-necology  are  performed  after  dilatation  of  the 
cervix  by  tents.  A  fatal  result  ensuing  is  commonly  attributed 
to  the  operation.  "With  my  experience  I  cannot  doubt  that  the 
preparatory  dilatation  is  accountable  for  it  in  many  cases. 

In  view  of  the  great  suddenness  with  which  the  dangerous  symp- 
toms which  follow  the  use  of  tents  develop  themselves,  I  confess 
myself  greatly  at  a  loss  to  account  for  the  method  by  which  they 
establish  the  morbid  train.  My  impression  is  that  the  tent  estab- 
lishes a  lymphangitis  or  angeioleucitis  in  the  abundant  network  of 
uterine  lymphatics,  and  that  from  this  source,  as  in  cases  of  dis- 
secting wounds,  a  rapid  advance  of  inflammation  takes  place  to 
6 


82  MEANS    OF    DIAGNOSIS. 

neighboring  parts.  In  this  way  the  peritoneum  and  pelvic  areolar 
tissue  are  reached;  in  this  way  septicaemia  develops  itself.  How 
else  could  these  parts  become  aftected  in  the  course  of  twelve  or 
twenty-four  hours  ?  Even  if  a  septic  endometritis  were  established 
which  reached  the  peritoneum  through  the  Fallopian  tubes,  peri- 
tonitis would  be  the  invariable  result,  which  is  not  the  case,  and 
the  development  of  this  would  probably  be  less  rapid. 

This  subject  is  one  of  so  great  imiiortance  that  I  deem  it  best 
before  leaving  it  to  enumerate  certain  rules  which  should  always 
govern  the  practitioner  who  resorts  to  this  valuable,  but  at  the 
same  time  unquestionably  hazardous,  method  of  diagnosis  and 
treatment. 

1st.  In  the  introduction  of  a  tent  no  force  whatever  should  be 
employed.  Should  that  first  essayed  not  pass  the  os  internum 
easily,  it  should  be  at  once  withdrawn,  and  either  bent  so  as  to 
follow  more  accurately  the  course  of  the  cervical  canal  as  ascer- 
tained by  the  probe,  or  exchanged  for  a  smaller  tent. 

2d.  A  tent  should  never,  under  any  circumstances,  be  introduced 
at  the  physician's  office  and  the  patient  allowed  to  go  home  with 
it  in  utero.  Such  practice  is  hazardous  in  the  extreme.  Even 
when  introduced  at  the  patient's  home  she  should  at  once  be  con- 
fined to  the  recumbent  posture  and  kept  perfectly  quiet. 

3d.  The  practitioner  should  always  investigate  as  to  the  previous 
existence  of  chronic  pelvic  peritonitis,  one  of  the  most  common  of 
the  diseases  of  women.  Should  it  have  existed,  tents  should  be 
carefully  avoided.  In  most  of  the  instances  in  which  I  have  seen 
dangerous  results  follow  their  use,  this  condition  had  previously  ex- 
isted and  been  excited  into  activity  again  hy  them. 

4th.  A  tent  should  never  be  allowed  to  remain  in  the  uterus 
more  than  twenty-four  hours,  and  if  it  be  compatible  with  the  ac- 
complishment of  the  desired  result,  it  should  be  removed  in  twelve 
hours. 

5th.  After  removal  of  a  tent,  the  vagina  should  be  washed  out 
with  an  antiseptic  fluid,  and  if  any  pain,  chilliness,  or  discomfort 
follow  the  removal,  opium  should  be  freely  administered  and  per- 
fect quietude  enjoined. 

6th.  After  removal  of  a  tent,  the  patient  should  be  kept  in  bed 
for  at  least  twenty-four  hours,  and  never  allowed  to  travel  before 
the  expiration  of  four  or  five  days. 

I  am  fully  aware  that  these  precautions  will  be  incredulously 
received  by  those  practitioners  who  have  habitually,  and  with  im- 
punity, inserted  tents  at  their  offices,  and  sent  the  patients  home 


THE    ASPIRATOR.  83 

with  directions  to  remove  them,  bji  means  of  the  cord,  on  the  next 
dciy.  But  it  is  the  duty  of  every  conscientious  man  to  give  weight 
to  the  experience  of  others.  If  it  were  essential  for  every  prac- 
titioner to  lose  one  patient  from  this  or  any  kindred  cause  before 
regarding  it  as  really  dangerous,  the  number  of  fatal  cases  would 
necessarily  grow  very  large. 

The  Exploring  IsTeedlb. — By  means  of  a  long,  delicate  needle, 
or  very  narrow  tube,  constituting  a  canula  for  a  trocar  the  size  of  a 
small  knitting-needle,  the  contents  and  characters  of  tumors  in  the 
pelvis  may  be  ascertained.  These  instruments  are  not  employed 
in  treating  cysts,  but  are  required  onl}^  to  remove  sufficient  fluid 
to  announce  the  character  of  tbe  contents  of  the  tumor.  Some- 
times a  tumor,  supposed  to  be  solid  and  irremediable,  is  thus  proved 
to  be  amenable  to  treatment. 

The  Aspirator. — To  whom  belongs  the  credit  of  originating  this 
method  of  evacuating  the  fluid  contents  of  tumors  or  cavities  I  am 
unable  to  say.  M.  Courty  alludes  to  it  as  a  method  of  emptying 
ovarian  cysts  in  use  ten  years  ago,  and  mentions  the  instruments 
em[)loyed  for  that  purpose  by  Buys,  Monro,  Guerin,  and  Boinet. 
To  M.  Dieulafoy,  of  Paris,  certainly  belongs  the  credit  of  system- 
atizing and  popularizing  it  to  such  an  extent  that  it  must  be  lool<:ed 
upon  as  a  great  resource,  not  only  for  diagnosis,  but  treatment  of 
many  of  the  morbid  states  with  which  the  gynecologist  is  called  to 
deal. 

This  method  consists  in  the  introduction  of  very  slender,  long 
needles  perforated  by  a  capillary  tube,  into  tumors  in  regard  to  the 
consistency  of  the  contents  of  which  it  is  desired  to  decide;  con- 
necting these  by  gutta-percha  tubes  with  a  glass  cylinder  in  which 
a  powerful  piston  plays  very  accurately,  and  creating  a  vacuum  in 
this  by  drawing  the  piston  upwards.  Powerful  suction  is  thus 
exerted  upon  the  fluid  in  the  cavity  penetrated  by  the  needle,  and 
if  not  too  tenacious  to  flow  through  so  small  a  needle,  it  passes 
through  the  tube  and  enters  the  cylinder.  Fig.  19  exhibits  the 
most  recent  modification  of  Dieulafoy's  aspirator.  Such  instru- 
ments, very  perfectly  constructed,  can  now  be  obtained  of  the 
instrument  makers  of  this  city. 

One  great  advantage  possessed  by  this  instrument  consists  in  the 
fact  that  the  needles  are  so  delicate  that  the  intestines,  the  bladder, 
solid  tumors,  or  even  important  secernent  organs  may  be  penetrated 
without  great  danger.     The  sac  imprisoned  in  intestinal  hernia, 


84  MEANS    OF    DIAGNOSIS. 

the  large  intestine  distended  by  gases,  the  bladder  threatened  with 
rupture  by  impassable  stricture,  have  all  been  tapped  by  it  with 

impunity. 

Fig.  19. 


Dieulafoy's  aspirator. 

Should  the  operator  not  have  this  instrument  at  his  disposal,  the 
same  principle  may  be  applied  to  diagnosis  by  the  use  of  the  ordi- 
nary hypodermic  syringe,  as  suggested  by  Dr.  II.  F.  Walker,  and 
sufficient  fluid  obtained  for  chemical  and  microscopical  examination. 

This  method  of  exploration  may  be  applied  to  all  pelvic  and  ab- 
dominal tumors,  with  the  best  results. 

The  Microscope. — The  microscope  will  often  prove  useful  as  an 
aid  in  diagnosis  in  determining  the  malignant  nature  of  certain 
morbid  growths,  the  character  of  products  of  inflammation,  the 
connection  of  intra-uterine  growths  with  conception,  the  purulent 
nature  of  uterine  leucorrhoea,  and,  as  Dr.  Sims  has  pointed  out, 
the  deleterious  effects  of  uterine  discharges  upon  the  zoosperm  in 
the  production  of  sterility.  In  several  cases  of  obstinate  metror- 
rhagia dependent  upon  an  unascertained  cause,  I  have  been  able, 
through  cervical  dilatation  and  the  use  of  the  curette,  to  obtain 
material  sufficient  for  a  positive  diagnosis  of  sarcoma  or  cancer  of 
the  body,  by  this  instrument.  One  case  has  come  to  my  knowledge 
in  which  many  of  the  symptoms  of  cancer  of  the  body  existed,  but 
in  which  the  error  in  diagnosis  thus  created,  was  corrected  by  re- 
moval of  a  portion  of  the  supposed  morbid  growth  and  examina- 
tion by  the  microscope.  By  this  instrument  the  substance  was 
pronounced  to  be  not  cancer  but  sponge,  and  further  investigation 
proved  that  one  half  of  a  sponge-tent  had  remained  in  the  body 
of  the  uterus  for  several  months.  A  similar  case  has  been  reported 
to  me,  in  which  a  piece  of  cotton  was  long  retained,  giving  rise  to 
very  anomalous  symptoms.  A  portion  being  removed,  the  micro- 
scope revealed  its  true  nature. 


.       AUSCULTATION    AND    PERCUSSION.  85 

III  the  diagnosis  of  ovarian  tumors  it  becomes  a  most  valuable 
resource.  By  it  the  fluid  removed  from  a  cyst  may  often  be  de- 
cided to  be  ascitic,  ovarian,  from  cysts  of  the  broad  ligament,  fibro- 
cystic, or  from  cysts  of  hydatid  origin.  In  solid  ovarian  tumors 
it  may  also  aid  and  settle  diagnosis.  Where,  for  example,  the 
question  of  operation  is  to  be  decided  by  the  benignity  of  the 
u-rowth,  an  explorative  incision  may  be  made,  a  small  portion  re- 
moved, and  all  doubts  be  put  at  rest.  Such  an  operation,  though 
dangerous  in  itself,  had  better  be  resorted  to  than  that  the  patient 
should  lose  the  prospect  of  life  held  out  to  her  by  ovariotomy. 

Auscultation  and  Percussion. — The  important  assistance  of 
auscultation  and  percussion  in  mapping  out  the  size  of  tumors,  de- 
termining pregnancy,  diflerentiating  this  from  ovarian  cysts,  etc., 
is  so  evident  as  merely  to  require  a  passing  mention. 

RECAPITULATION    OP    MEANS    FOR  EXPLORING  THE  VISCERA  AND  TISSUES  OP 

THE    PELVIS. 

Ist.  Vagina  and  Cervix — 

Vaginal  touch; 

Sight,  through  the  speculum  ; 

Conjoined  manipulation. 
2d.   Outer  Surface  of  the  Uterus — 

Vaginal  and  rectal  touch,  while  the  organ  is  brought 
within  reach  by  hypogastric  pressure  or  the  tenacu- 
lum ; 

Conjoined  manipulation; 

Vesico-rectal  exploration ; 

Simon's  method. 
Zd.  Cavity  of  Cervix  and.  Body — 

Tents,  followed  by  introduction  of  finger; 

The  uterine  probe  and  sound; 

Removal  of  substance  by  curette  and  use  of  microscope. 
Ath.   The  Ovaries^  Broad  Ligaments,  Pelvic  Peritoneum,  and  Pelvic 
Areolar  Tissue — 

Vaginal  touch; 

Rectal  touch; 

Simon's  method ; 

Conjoined  manipulation; 

Abdominal  palpation; 

Auscultation  and  percussion; 

The  exploring  needle; 

The  aspirator. 


86  DISEASES    OF    THE    VULVA. 


CHAPTER    IV. 

DISEASES    OF    THE    VULVA. 

Normal  Anatomy.— The  vulvu  is  the  elliptical  opening  which 
exists  at  the  distal  extremity  of  the  vagina,  and  comprises  the 
mons  veneris,  labia  majora  and  minora,  clitoris,  meatus  urinarius, 
vestibule,  fossa  navicularis,  fourchette,  and  hymen. 

Labia  3Iajora. — From  the  mons  veneris,  which  consists  of  adi- 
pose tissue  covered  by  skin  in  which  exist  numerous  hair-bulbs, 
two  folds  of  integument  pass  downwards  to  unite  at  the  fourchette. 
These  are  called  the  labia  majora.  Externally  they  are  covered 
by  skin,  which  contains  scattered  hair-bulbs,  but  on  their  inner 
surfaces  their  covering  is  mucous  membrane,  which  is  studded 
with  sebaceous  follicles,  the  secretion  of  which  is  unctuous  and 
semi-solid.  These  glands  are  remarkably  large,  reaching,  according 
to  E.  Klein,^  a  diameter  of  0.5  millimetre.  They  open  immedi- 
ately upon  the  free  surface. 

Within,  the  labia  are  filled  with  adipose  tissue,  a  portion  of 
which  is  inclosed  in  sacs,  of  which  one  arises  from  each  external 
abdominal  ring  and  extends  downwards  towards  the  fourchette. 
To  these  Broca  has  given  the  name  of  dartoid  sacs. 

The  Clitoris. — Beneath  the  superior  commissure  of  the  labia  juts 
forward  a  little  erectile  organ,  which  is  analogous  to  the  penis  of 
the  male,  and  receives  the  name  of  clitoris.  It  is  covered  by  mu- 
cous membrane,  consists  of  erectile  tissue,  and  arises  by  two  rami, 
one  of  which  is  attached'  to  each  ramus  of  the  pubes.  Like  the 
male  penia,  this  little  organ  is  provided  with  a  prepuce  and  frsenum. 

Labia  3Iinora, — These  consist  of  two  folds  which,  arising  at  the 
clitoris,  pass  downwards  and  disappear  about  half  way  between  the 
two  commissures.  Like  the  clitoris  they  are  formed  of  erectile 
tissue  covered  over  by  mucous  membrane,  and  an  attentive  exami- 
nation discovers  upon  their  surfaces  a  large  number  of  glands, 
which  secrete  a  sebaceous  material. 

The  Fossa  Navicularis  and  Vestibule  are  merely  spaces  inter- 

'  Strieker's  Manual  of  Histology. 


VULVITIS.  87 

vening;  the  first,  between  the  perineum  and  vagina;  the  second, 
between  the  meatus  and  clitoris.  They  are  both  covered  by  mu- 
cous membrane,  and  the  latter  is  studded  with  follicles. 

The  Hymen'  is  a  thin  veil  consisting  of  a  double  fold  of  mucous 
membrane,  which  in  part  closes  the  ostium  vaginae.  When  rup- 
tured its  remains  contract  and  form  little  tubercles  on  the  walls  of 
the  vagina. 

Passing  over  the  clitoris,  to  which  it  is  attached,  and  running 
downwards  on  each  side  of  the  vulva  so  as  in  part  to  cover  the 
bulbi  vestibuli,  will  be  found  a  muscle,  which  is,  I  think,  very  gene- 
rally, regarded  as  the  sphincter  vagina3.  Savage^  denies  that  it  (the 
bulbo  cavernous  muscle)  has  any  such  influence,  the  true  sphincter 
vaginae  being  the  pul)0-coccygeus  muscle,  which  is  seen  by  dissection 
within  the  pelvis,  arising  from  the  inner  surface  of  the  pubic  bones. 
Descending  on  the  sides  of  the  vagina  some  of  its  fibres  pass  between 
it  and  the  rectum  to  meet  others  from  the  opposite  side  in  the  peri- 
neum. Another  set  go  behind  the  rectum,  and  uniting  with  similar 
ones  from  the  opposite  side,  intermix  with  its  circular  fibres  to  make 
the  internal  sphincter.  The  remaining  fibres,  still  more  outward, 
are  inserted  into  the  sides  of  the  coccyx. 

Vulvitis. 

Definition. — Vulvitis  is  the  name  applied  to  inflammation  of  the 
mucous  membrame  lining  the  vulva.  Affecting  all  of  this  struc- 
ture, the  surface  covered  by  epithelium  and  the  glands  imbedded 
in  it,  the  inflammatory  action  sometimes  extends  through  the  sub- 
mucous tissue  into  the  proper  structure  of  the  parts  underlying  it, 
creating  tumefaction,  pain,  and  sometimes  even  suppuration. 

Varieties. — Authorities  dift'er  with  regard  to  the  classification  of 
its  varieties. 

That  which  appears  most  appropriate  is  the  following  : — 

Purulent  vulvitis ; 
Follicular  vulvitis ; 
Gangrenous  vulvitis. 

Purulent  Vulvitis. 

This  variety  of  the  afi*ection  may  be  either  of  non-specific  form, 
or  a  true  gonorrhoea  of  the  vulva.  The  former  is  in  many  respects 
analogous  to  balanitis  in  the  male,  while  the  latter  resembles  very 

'  Female  Pelvic  Organs,  2d  ed. 


88  DISEASES    OF    THE    VULVA. 

closely  specific  inflammation  in  other  mucous  membranes  of  the 
body. 

Causes. — It  may  result  from  | 

Viiginitis,  specific  or  simple ;  I 

Want  of  cleanliness  ;  .  | 

Injury,  or  friction  from  exercise;  * 

Eruptive  disorders ; 
Onanism  ; 
Chemical  irritants ; 
Excessive  venery. 

Symptoms. — The  parts  are  red,  swollen,  hot,  and  at  first  dry.  Then 
a  free  flow  of  pus  takes  place  which  bathes  the  whole  surface  and 
stains  the  linen  of  a  yellow  hue.  In  addition  to  these  signs  of 
active  inflammation,  superficial  ulcers  will  be  found  scattered  over 
the  parts  aft'ected,  and  in  rare  cases  patches  of  diphtheritic  mem- 
brane will  be  seen  adhering  to  them.  At  times  the  meatus  urina- 
rius  becomes  afi'ected,  and  painful  micturition,  with  scalding  and 
heat,  is  complained  of.  At  others  the  most  intense  pruritus  attects 
the  vulva,  and  the  patient,  in  endeavoring  to  obtain  relief,  may 
contract  the  habit  of  masturbation.  Should  the  inflammation 
extend  to  the  vagina,  the  symptoms  of  vaginitis  will  also  show 
themselves,  and  by  a  similar  extension  to  the  bladder  those  of  cys- 
titis may  develop.  In  severe  cases  febrile  action,  with  thirst,  heat 
of  skin,  and  general  discomfort,  is  present,  but  this  is  not  usually 
the  case. 

The  pus  which  is  discharged,  always  in  the  specific  form  of  the 
disease,  and  very  generally  in  the  non-specific,  gives  forth  a  dis- 
agreeable odor,  and  is  usually  so  irritating  in  its  nature  as  to  excori- 
ate the  inner  surfaces  of  the  thighs  when  it  comes  in  contact  with 
them.  Should  this  material,  even  in  the  non-specific  form  of  the 
affection,  be  carelessly  brought  in  contact  with  the  conjunctivae,  a 
severe  form  of  purulent  ophthalmia  is  excited.  The  late  Professor 
Bedford  gave  me  the  account  of  a  case  in  which  coition  under  such 
circumstances  gave  rise  to  a  urethritis  in  the  male,  which  was  made 
the  basis  of  a  suit  for  divorce.  He  was  applied  to  as  a  medical 
expert,  and  found  upon  examination  that  non-specific  purulent  vul- 
vitis, uncomplicated  by  vaginitis  or  urethritis,  existed. 

Course  and  Termination. — Even  without  treatment  it  is  probable 
that  the  affection  would  always  be  recovered  from  in  time  ;  but  it 
would  run  a  lengthy  and  tedious  course,  and  perhaps  give  rise  to 
complications  which  would  be  productive  of  greater  evil  than  the 


FOLLICULAR    VtJLVlTIS.  89" 

original  disorder.     When  properly  treated,  it  generally  runs  a  rapid 
course  and  is  readily  cured. 

Treatment. — If  inflammatory  action  be  excessive,  the  patient 
should  be  kept  in  bed,  upon  low  diet,  and  the  bowels  freely  acted 
upon  by  saline  cathartics.  Cooling  and  emollient  applications 
should  be  made  constantly  to  the  inflamed  part,  and  cleanliness 
scrupulously  observed.  The  patient  should  be  directed  to  bathe 
the  vulva  freely  with  warm  water  three  or  four  times  daily,  and  to 
apply  a  warm  poultice  of  powdered  linseed,  slippery  elm,  or  grated 
potato.  To  the  poultices  may  be  added  with  advantage  a  solution 
of  actetate  of  lead  and  tincture  or  powder  of  opium. 

As  soon  as  the  acute  action  has  subsided,  the  lead  and  opium 
wash  should  be  kept  in  contact  with  the  parts,  by  dossils  of  lint 
soaked  in  it,  and  placed  between  the  labia.  It  is  thus  com- 
pounded : — 

R.  Tr.  opii,  sij. 

Plumbi  acetat.,      3j. 
Aquae,  Oj. — M. 

At  a  still  later  period  the  diseased  surface  should  be  painted 
over  several  times  a  day  with  a  solution  of  persulphate  of  iron  and 
glycerine,  one  part  of  the  former  to  eight  of  the  latter.  Should 
the  disorder  not  be  entirely  eradicated  by  this  treatment,  the  vulva 
may  be  painted  over  once  in  every  forty-eight  hours  with  a  solution 
of  nitrate  of  silver,  ten  grains  to  the  ounce  of  water,  and  kept  con- 
stantly powdered  with  lycopodium,  bismuth,  or  starch,  until  re- 
covery is  complete.  Should  pruritus  attend  the  latter  stages  of  the 
disorder,  a  wash  composed  of  one  scruple  of  carbolic  acid  to  one 
pint  of  water  will  be  found  useful. 

Follicular  Vulvitis. 

Definition  and  Synonyms. — It  has  been  already  stated  that  in  the 
mucous  membrane  lining  the  vulva,  more  especially  in  that  cov- 
ering the  labia  majora,  labia  minora,  and  vestibule,  numerous 
follicles  exist.  Presenting  themselves  as  solitary  glands,  they  are 
classified  under  the  three  following  heads — muciparous,  sebaceous, 
and  piliferous.  In  ordinary  purulent  vulvitis,  these,  as  com- 
ponent parts  of  the  diseased  membrane,  are  implicated  in  the 
morbid  action.  Sometimes,  however,  they  alone  are  affected  by 
disease,  when  the  name  of  follicular  vulvitis  or  vulvar  folliculitis 
has  been  applied  to  the  condition.  Any  or  all  the  varieties  of 
glands  just  mentioned  may  be  diseased,  and  authors  have  given 
special  names  to  the  varieties,  so  that  a  list  which  would  com- 


90 


DISEASES    OF    THE    VULVA, 


prise  them  all  would  be  a  long  one.  As  examples  may  be  men- 
tioned papillary,  pruriginous,  erythematous,  sebaceous,  granular 
vulvitis,  etc. 

We  may  avoid  tediousness  of  detail,  and  at  the  same  time  run 
no  risk  of  being  led  into  error,  by  classing  all  forms  of  inflamma- 
tion aflecting  the  solitary  glands  of  the  vulva  under  the  head  of 
follicular  vulvitis;  provided  that  we  bear  in  mind  that  all  the 
varieties  of  glands  may  be  simultaneously  atiected,  or  that  one  set 
alone  may  be  diseased,  the  others  remaining  healthy. 

Causes.— This  form  of  vulvitis  may  be  induced  by  the  following 
influences: — 

Pregnancy ; 

Neglect  of  cleanliness; 

Vaginitis; 

Exanthemata; 

Eruptions  on  the  vulva. 

Symptoms. — There  are  burning,  itching,  and  heat  in  the  vulva, 
with  increase  of  glandular  secretion.     At  times  the  secretion  is 

excessively  oflensive  and  irritat- 


Fig.  20. 


ing  in  character.  The  urethra 
frequently  becomes  inflamed  at 
its  vulvar  extremity,  and  scald- 
ing in  the  passage  of  urine  re- 
sults. The  vulva  may  become 
so  sensitive  to  touch,  that  efforts 
at  sexual  intercourse  excite  va- 
ginismus, which  thus  constitutes 
a  symptom  of  the  disease. 

Physical  Signs. — If  the  muci- 
parous follicles  be  chiefly  aflPected, 
the  mucous  membrane  of  the 
vulva  will  be  found  intensely 
red  in  spots  or  patches,  which  are 
slightly  elevated.  These  are 
most  commonly  found  on  the 
edges  of  the  lower  vaginal  rugse, 
the  nymphfe,  and  the  carunculae. 
They  sometimes  resemble  the 
swollen  villi  upon  the  tongue, 
and  bleed  upon  slight  irritation. 
Should  the  disease  have  affected  chiefly  the  sebaceous  and  pi- 
liferous  glands,  little,  red,  rounded  papillae  will  be  found  on  the 


Follicular  vulvitis      (Hnguier  ) 


FOLLICULAR    VULVITIS.  91 

surfaces  of  the  labia  majora  and  minora,  and  the  base  of  the  pre- 
puce of  the  clitoris.  After  a  while  a  drop  of  pus  will  appear  in 
the  apex  of  each,  which  is  soon  discharged,  and  the  distended  fol- 
licle shrivels.  Beneath  the  labia  minora  a  semi-fluid  mass  of  oft'en- 
i^ive  secretion  will  generally  be  found,  which  will,  if  not  carefully 
removed,  conceal  the  follicles  underlying  it. 

Course  and  Duration. — If  this  disorder  occur  during  pregnancy, 
it  may  disappear  at  its  conclusion.  In  some  cases  it  becomes  so 
severe,  and  produces  such  annoying  symptoms,  that  abortion  is 
induced  by  it.  If  it  exist  in  the  non-pregnant  state,  and  be  not 
appropriately  treated,  it  may  continue  for  an  unlimiited  time  and 
establish  urethritis,  not  only  in  the  patient,  but  in  her  husband. 
This  fact  should  be  especially  recollected,  for  a  suspicion  of  want 
of  chastity  may  be  excited  in  the  mind  of  tb-e  husband,  and  serious 
domestic  difficulty  result. 

Treatment — Follicular  vulvitis  should  be  treated  upon  the  same 
principles  as  the  purulent  form  ;  by  repeated  ablution,  warm  poul- 
tices, sedative  washes,  and  local  alteratives,  especially  the  persul- 
phate of  iron  and  nitrate  of  silver.  Dr.  Oldham,  who  was  one  of 
the  first  to  enlighten  the  profession  in  regard  to  this  affection,  placed 
great  confidence  in  the  following  prescription : — 

R. — Acidi  hydrocyanici  dil.,  ^ij. 
Plumbi  diacetatis,  9j. 
Olei  cacao,  ^ij. — M. 
S.  Apply  after  washing  the  parts  with  cold  water. 

The  chronic  form  of  this  affection,  which  is  fortunately  rarely 
met  with,  constitutes  a  really  formidable  and  uncontrollable  disease. 
In  the  American  Journal  of  Obstetrics  will  be  found  a  remarkable 
instance  of  it  reported  by  Dr.  B.  F.  Dawson,  which,  as  typical  of 
that  form  of  the  disorder,  is  worthy  of  especial  notice.  The 
patient,  aged  60  years,  had  suffered  from  follicular  vulvitis  since 
the  age  of  16,  and  after  consulting  numerous  practitioners  in  vain, 
had,  on  account  of  the  intolerable  itching  attending  the  disease, 
l)een  induced  to  resort  to  opium  for  comfort,  until  in  time  she  had 
Ijecome  a  confirmed  opium-eater.  At  the  time  when  the  history 
was  given,  the  following  was  the  condition  of  the  vulva:  "On 
parting  the  labia,  which  had  to  be  done  with  the  utmost  gentle- 
ness, as  the  patient  suffered  and  flinched  at  every  attempt,  the 
mucous  membrane  of  the  labia,  as  well  as  the  fourchette,  was  found 
completely  covered  over  by  a  thick  cheesy  substance,  of  a  dirty 
cream  color,  which  emitted  a  peculiarly  offensive  odor."     This  con- 


92  DISEASES    OF    THE    VULVA. 

dition  had  proved  so  entirely  rebellions  to  treatment,  that  removal  i 
of  the  entire  mucous  covering  of  the  vulva  which  was  the  site  of 
the  diseased  glands  had  to  be  resorted  to. 

Gangrenous  Vulvitis. 

Definition  and  Synonyms. — This  singular  disease,  which  is  in 
many  of  its  attributes  akin  to  the  cancrum  oris  of  children,  has 
been  synonymously  described  under  the  names  of  noma,  carbuncle 
of  the  genitals,  gangrene  of  the  vulva,  etc.  It  is  fortunately  a 
very  rare  aftection,  as  it  commonly  proceeds  to  a  fatal  issue. 

Pathology. — A  survey  of  the  predisposing  causes,  none  which  are 
exciting  being  known,  will  convince  the  reader  that  this  form  of 
vulvitis,  unlike  the  other  afiections  of  the  genital  organs  which  we 
have  just  considered,  is  dependent  upon  a  depraved  blood  state, 
one  somewhat  similar  to  that  which  produces  like  results  in  the 
mouth  and  fauces  in  continued  fevers,  scarlatina,  etc. 

Causes. — The  conditions  which  are  known  to  result  in  it  are — 

Peculiar  epidemics  of  puer[)eral  fever; 
An  unknown  epidemic  influence ; 
Scarlatina,  measles,  and  continued  fever. 

The  affection  has  sometimes  been  observed  to  take  on  an  epidemic 
character  like  similar  disorders  in  the  throat  and  mouth. 

Symptoms. — Yelpeau^  describes  these  in  the  following  graphic 
manner :  "A  patch  or  vesicle  of  grayish,  reddish,  or  blackish  hue, 
which  ulcerates  and  soon  becomes  depressed  in  the  midst  of  swollen 
and  indurated  tissues  which  are  of  a  red  color,  forms  generally  the 
point  of  departure.  From  this  moment  the  gangrene  advances 
step  by  step;  mortification  affects  the  parts;  an  ichorous,  fetid, 
nauseating  fluid  pathes  the  labia  majoi-a  ;  separation  of  the  gan- 
grenous patches  takes  place  slowly,  and  instead  of  limiting  itself 
the  process  of  destruction  continues  sometimes  to  extend  until  the 
death  of  the  patient.  The  vital  forces  rapidly  break  down,  and 
many  children  would  die  of  this  dreadful  affection  if  art  did  nor. 
promptly  interpose." 

A  swollen,  purplish,  and  oedematous  state  of  the  labia,  accompa- 
nied by  grave  constitutional  signs,  in  one  exposed  to  any  of  the  pre- 
disposing causes  mentioned,  would  at  once  excite  the  suspicion  of  a 
practitioner  at  all  familiar,  even  in  theory  only,  with  the  existence 
of  this  malady.     The  only  disease  with  which  it  would  probably 


»  Diet,  de  M6d.,  vol.  xxx,  p.  991. 


INFLAMMATION    OF    THE    VUL  VO- V  A  G  IN  A  L    GLANDS.     93 

be  confounded  is  diphtheria  of  the  vulva,  and  this  would  readily 
be  differentiated  by  the  patches  of  false  membrane  which  would 
cover  the  mucous  lining  of  the  part. 

Treatment. — As  soon  as  the  nature  of  the  disease  is  ascertained, 
both  constitutional  and  local  treatment  should  be  promptly  and 
energetically  established.  The  patient  should  be  placed  in  bed, 
iu  an  apartment  supplied  by  the  purest  air,  and  all  depressing  in- 
fluences should  be  removed  from  her.  The  most  nutritious  food  and 
wine  or  otlier  stimulants  should  be  administered,  and  the  strength 
sustained  by  quinine  and  muriated  tr.  of  iron  in  large  and  repeated 
iloses.  If  the  local  disorder  be  not  rapidly  arrested,  death  will 
undoubtedly  ensue  in  spite  of  all  general  means,  and  no  time 
should  be  lost  in  trying  inefficient  remedies.  A  powerful  caustic 
is  the  only  hope.  The  gangrenous  spot  should  be  destroyed  by 
the  actual  cautery  or  muriatic  or  nitric  acid,  the  patient  being 
under  the  anaesthetic  influence.  After  this,  disinfectant  poultices 
should  be  applied,  and  every  effort  at  sustaining  the  vital  forces 
continued.  Should  a  fresh  gangrenous  spot  appear,  a  new  applica- 
tion of  the  caustic  should  be  resorted  to. 

Cyst  and  Abscess  of  the  Vulvo -Vaginal  Glands. 

Anatomy. — Just  anterior  to  the  hymen,  or  the  carunculse  myrti- 
formes,  will  be  found  on  each  side  a  little  opening,  sufficiently  large 
to  admit  a  small  probe  or  bristle.  This  opening  leads  through  a 
canal  three-fifths  of  an  inch  long,  which  is  the  excretory  duct  of  a 
conglomerate  gland  which  has  received  the  name  of  vulvo-vaginal 
gland.  These  glands  are  found,  one  on  each  side  of  the  ostium 
vaginee,  between  the  vagina  and  the  ascending  branch  of  the  is- 
chium, from  which  they  are  distant  three-tenths  of  an  inch,  and 
lie  in  contact  with  the  transverse  artery  of  the  perineum.  The  fact 
that  they  are  separated  from  the  vagina  by  an  aponeurotic  prolon- 
gation, lie  between  the  superficial  and  middle  layers  of  the  ischio- 
pubic  fascia,  and  have  the  unyielding  ischium  on  one  side,  accounts 
for  the  complete  confinement  of  pus  forming  in  them,  and  its  not 
being  discharged  by  the  rectum  or  vagina.  They  were  described 
by  Duverney,  Bartholinus,  Morgagni,  and  their  immediate  succes- 
sors, but  in  time,  very  singularly,  they  were  forgotten.  In  1841, 
M.  Huguier,  of  Paris,  redescribed  them  fully,  and  threw  much  light 
upon  their  diseased  conditions. 

Sometimes,  their  mouths  becoming  occluded  by  adhesive  inflam- 
mation, their  secretion  is  retained,  and  they  undergo  great  enlarge- 


94  DISEASES    OF    THE    VULVA. 

ment  and  distention.  At  other  times  suppurative  inflammation  is 
set  up  and  abscess  is  the  result. 

Causes. — The  causes  of  inflammation  of  these  glands  are  very 
much  the  same  as  those  of  vulvitis,  of  which,  indeed,  this  affection 
is  often  a  concomitant  disorder. 

Symptoms. — There  is  heat  about  the  vulva,  pruritus,  and  pain 
upon  touch.  The  mouth  of  the  duct  is  red,  and  the  finger  pressed 
over  the  site  of  the  gland  discovers  a  hard,  painful,  and  perhaps 
fluctuating  tumor  about  the  size  of  a  small  hen's  egg.  Very  often 
the  first  intimation  of  the  existence  of  the  disease,  is  given  by  pain 
durino;  the  sexual  act. 

Differentiation. — An  abscess  of  this  gland  is  readily  distinguished 
from  a  cyst  by  the  presence  of  the  ordinary  signs  of  inflammation. 
From  phlegmonous  inflammation  of  the  labium  majus  it  will  be 
known  by  its  distinct,  globular,  and  limited  outline,  the  former 
affection  being  diffuse.  Furuncles  are  entirely  too  superficial  to 
create  confusion  in  diagnosis. 

Course  and  Duration. — This  disease  is  one  of  no  great  moment,  and 
its  natural  tendency  is  to  recovery.  Its  usual  duration  is  from 
two  to  three  weeks,  and  the  inflammatory  process  may  terminate 
either  by  resolution  or  by  suppuration.  Should  the  latter  occur, 
the  pus  may  be  discharged  through  the  ducts  of  the  gland,  or  in  the 
furrow  between  the  labia  minora  and  majora.  In  some  cases, 
however,  the  gland  becomes  filled  with  a  honey-like  matter,  and 
exists  as  a  cyst  for  a  number  of  months,  and  I  am  inclined  to  think 
even  for  years. 

Treatment. — An  emollient  poultice  or  cooling  and  anodyne  lotion 
should  be  kept  applied  to  the  vulva,  and  rest  should  be  prescribed 
until  suppuration  has  occurred.  Then,  if  pain  be  very  severe,  the 
accumulated  pus  may  be  evacuated,  by  means  of  a  lancet,  near  the 
mouth  of  the  gland  or  at  any  other  point  where  fluctuation  is  most 
distinct.  If  pain  be  not  severe,  the  evacuation  of  the  pus  may  be 
left  to  nature. 

When  frequent  return  of  the  morbid  process  makes  it  advisable 
to  resort  to  an  operation  to  give  permanent  relief,  extirpation  of 
the  gland  may  be  practised.  An  incision  should  be  made  at  the 
point  where  one .  labium  minus  unites  with  the  labium  majus, 
through  which  the  gland  may  be  seized  by  forceps  and  dissected 
out  with  scissors.  The  transversus  perinei  artery  will  probably 
be  severed,  and  should  be  ligated  for  fear  of  hemorrhage.  I  have 
never  found  it  necessary  to  extirpate  the  gland.  When  repeated 
collections  of  pus  or  of  its  proper  secretion  have  occurred,  I  have 


ERUPTIVE    DISEASES    OF    THE    VULVA.  95 

succeeded  in  efteeting  permanent  relief  by  opening  the  sac  freely 
and  stuffing  it  with  greased  lint,  so  as  to  cause  the  healing  process 
to  begin  at  the  bottom.  Or  the  same  result  has  been  obtained  by 
evacuation  of  the  contents  of  the  sac  and  the  introduction  of  a 
stick  of  nitrate  of  silver  so  as  to  cauterize  its  walls  and  the  edges 
of  the  opening. 

Eruptive  Diseases  of  the  Vulva. 

The  skin  and  mucous  membrane  making  up  the  vulva  may,  like 
the  same  structures  in  other  parts  of  the  body,  be  aflected  by  erup- 
tive disorders  of  various  kinds.  It  is  not  my  intention  to  enter 
with  any  minuteness  into  the  consideration  of  these  diseases,  for 
which  I  refer  the  reader  to  any  of  the  modern  works  upon  derma- 
tology, but  merely  to  note  the  fact  that  they  may  occur  upon  this 
part,  and  mention  the  leading  characteristics  of  the  most  frequent 
of  them. 

Any  eruptive  disorder  which  may  elsewhere  aftect  the  skin  or 
mucous  membrane  of  the  body  may  show  itself  on  the  vulva.  The 
following  list  includes  those  which  are  most  commonly  met  with 
and  most  frequently  call  for  diagnosis  and  treatment: — 

Prurigo  and  lichen; 

Eczema ; 

Acne ; 

Elephantiasis; 

Erythema  and  erysipelas; 

Syphilides. 

As  is  the  case  elsewhere  with  prurigo,  that  of  the  vulva  presents 
large,  scattered  papules,  very  irritating,  and  generally  having  their 
apices  bereft  of  cuticle.  Lichen  shows  more  numerous  papules, 
which  rest  upon  a  thickened  and  somewhat  indurated  cutaneous 
base.  Pruritus  vulvae  is  the  most  prominent  symptom  of  these 
maladies.  So  intense  is  the  irritation  of  the  vulva  established  by 
til  em  that  vulvitis  is  the  consequence,  the  disease  then  being  styled 
prurigenous  vulvitis. 

In  eczema  the  surface  is  red,  heated,  and  covered  by  little  vesi- 
cles, which  breaking,  give  forth  a  serous  fluid.  The  eruption  con- 
fines itself  chiefly  to  the  cutaneous  surface,  the  mucous  lining  being 
less  affected.  It  may  pass  off  rapidly  as  an  acute  disorder,  but 
sometimes  there  are  successive  crops  of  vesicles  which  exhaust  the 
strength  of  the  patient,  in  consequence  of  the  nervous  excitement 
and   irritability  which  the  disease   induces.     In  many  cases  of 


96  DISEASES    OF    THE    VULVA. 

diabetes  and  vesico-vaginal  fistula,  this  aflfection  constitutes  an  ex- 
ceedingly annoying  and  even  painful  complication. 

Acne  consists  in  engorgement  of  the  sebaceous  follicles  studding 
the  labial  faces;  not  in  active  inflammation,  which  would  bring  the 
case  under  the  head  of  follicular  vulvitis,  but  in  engorgement  by 
their  own  retained  secretion. 

Elephantiasis  of  the  labia  difters  in  nothing  from  that  of  other 
parts.  The  aifection  is  very  rare.  Kiwisch  records  one  case  in 
which  both  labia  increased  in  size,  so  as  to  equal  the  head  of  a 
man,  and  to  fall  nearly  to  the  knees.  The  parts  affected  by  it  are 
the  labia  majora  and  minora,  the  clitoris,  and  the  perineum. 

Erythema  and  erysipelas  are  simply  accompanied  by  graver  symp- 
toms when  they  afltect  the  genital  organs  than  when  they  develop 
on  the  skin  elsewhere. 

Syphilis  in  secondary  and  tertiary  form  may  affect  the  labia, 
creating  hypertrophy,  ulceration,  and  all  the  evils  which  it  excites 
in  other  parts. 

These  disorders  create  the  ordinary  symptoms  of  vulvitis,  and 
hence  they  are  commonly  confounded  with  it.  Pruritus  vulvse  is 
one  of  their  most  constant  signs,  and  the  itching  which  it  produces 
often  first  attracts  attention  to  their  presence. 

Treatment. — Little  need  be  said  here  of  treatment,  for  it  should 
be  guided  by  the  rules  which  govern  the  management  of  the  same 
cutaneous  disorders  in  other  parts  of  the  body.  The  general  health 
should  be  carefully  attended  to;  change  of  air  advised;  and  tonics 
and  alteratives,  such  as  iron  and  arsenic,  prescribed  in  combination, 
the  first,  with  Colombo,  or  the  second,  with  the  tinctures  of  cincho- 
na, or  gentian.  Local  treatment  should  consist  in  the  maintenance 
of  strict  cleanliness  by  bathing  the  diseased  parts  freely  in  tepid 
water,  and  the  pruritus,  which  invariably  exists  and  leads  to  scratch- 
ing, should  be  relieved  by  lotions  containing  acetate  of  lead,  opium, 
borax,  or  a  small  amount  of  creasote  or  carbolic  acid. 

Phlegmonous  Inflammation  of  the  Labia  Majora. 

The  areolar  and  adipose  tissues,  which  in  great  degree  make  up 
the  bulk  of  the  labia  majora,  are  very  frequently  the  seat  of  inflam- 
mation and  abscess.  The  disease  is  excited  by  irritating  vaginal 
secretions,  vulvitis,  direct  injury,  and  the  peculiar  blood  state  which 
results  in  the  development  of  furuncles  and-  carbuncles. 

Symptoms. — In  the  first  stage  there  is  active  congestion,  which 
in  the  second  produces  hardness  and  tension  from  effusion  of  liquor 
sanguinis  into  the  areolar  tissue.     The  third  stasre  consists  in  the 


RUPTURE  OF  THE  BULBS  OF  THE  VESTIBULE. 


97 


breaking  down  of  this  mass  by  the  process  of  suppuration  and 
formation  of  an  abscess.  The  pus  which  is  thus  created  is  usually 
very  offensive  from  propinquity  to  the  rectum  and  vulva. 

The  diagnosis  is  usually  very  easy.  Attention  is  directed  to  the 
part  by  heat,  pain,  throbbing,  difficulty  of  locomotion,  and  exquisite 
sensitiveness  upon  pressure.  Upon  physical  exploration  one  labium 
is  found  very  much  swollen  and  quite  hard  and  tender.  Although 
it  is  usually  easy  to  distinguish  this  disease,  care  must  always  be 
taken  to  diflterentiate  it  from  labial  hernia,  displacement  of  an 
ovary,  pudendal  hematocele,  oedema  labiorum,  and  vulvitis.  As 
this  point  will  engage  our  attention  elsewhere,  it  requires  no  further 
mention  here. 

Treatment. — The  treatment  should  consist,  in  the  first  stage,  in 
the  application  of  cold  and  sedative  lotions,  low  diet,  saline  cathar- 
tics, and  perfect  rest.  One  of  the  best  local  applications  will  be 
found  to  be  the  lead  and  opium  wash.  As  the  second  stage  ad- 
vances the  process  of  suppuration,  which  is  now  inevitable,  should 
be  encouraged  by  poultices,  and  as  soon  as  'pus  is  distinctly  dis- 
coverable it  should  be  evacuated  by  puncture.  Early  opening  is 
advisable,  because  the  tissues  obstinately  resist  natural  evacuation, 
and  the  accumulation  may  pass  upwards  towards  the  abdominal 
ring  through  the  dartoid  sac. 

Rupture  of  the  Bulbs  of  the  Vestibule. 

Anatomy. — If  an  incision  be  made  by  a  scalpel  through  the  skin 
and  its  subjacent  adipose   tissue,  around  the  vulva,  and  all    the 

Fig.  21. 


Plexus  of  veius  of  the  vestibule.     (Kobelt. ) 


98  DISEASES    OF    THE     VULVA. 

tissues  making  up  that  part  be  dissected  oft',  a  reticulated  plexus  of 
large  veins  will  be  found  beneath  the  labia  called  the  pars  interme- 
dia and  bulbi  vestibuli.  These  extensive  channels  for  blood  have 
been  represented  by  Kobelt,  as  shown  in  Fig,  21. 

Any  influence  which  causes  a  rupture  of  these  vessels  must  pro- 
duce one  of  two  eftects ;  if  there  be  a  corresponding  rupture  of  the 
skin,  a  free  hemorrhage  will  occur  known  as  pudendal  hemorrhage  ; 
if  not,  the  blood  pouring  out  into  the  areolar  tissue,  surrounding 
the  wounded  plexus,  will  soon  form  a  coagulum,  constituting  a 
bloody  tumor,  which  has  received  the  name  of  thrombus  or  pudendal 
hematocele. 

Pudendal  Hemorrhage. 

Especial  attention  was  called  to  this  condition  by  Sir  James 
Simpson,^  wlio,  in  1850,  recorded  from  his  own  experience,  and 
that  of  others,  a  number  of  instances  in  which  from  a  very  slight 
rupture  of  one  labium  fatal  hemorrhage  took  place.  He  declared 
that  criminal  cases  had  repeatedly  occurred  in  Scotland,  in  which 
women,  both  pregnant  and  non-pregnant,  had  suddenly  died  from 
pudendal  hemorrhage,  arising  from  rupture  of  the  bulbs  of  the 
vestibule.  Suspicion  of  injury  at  the  hands  of  the  husbands  or 
neighbors,  had  been  entertained  in  most  or  all  of  the  instances 
referred  to. 

The  accident  is  a  rare  one.  But  two  instances  have  come  under 
my  notice,  one  occurring  in  consequence  of  puncture  of  the  labium 
by  a  stick,  the  woman  falling  in  crossing  a  fence ;  the  other  the 
result  of  a  similar  puncture  by  a  piece  of  china,  from  the  break- 
ing of  a  pot  de  chambre.  Both  these  cases  readily  yielded  to  the 
recumbent  posture,  and  the  application  of  cold  and  styptic  com- 
presses. A  very  interesting  case,  the  details  of  which  I  cannot  now 
find,  has  been  recently  published  in  one  of  the  journals  of  the  day. 
A  lady,  standing  upon  a  chair  to  mount  a  horse,  slipped  and  fell,  so 
as  to  cause  the  sharp  extremity  of  one  of  the  upright  jiieces  to 
puncture  one  labium.  Bleeding  was  profuse,  and  so  obstinate  as  to 
require  several  attempts  at  checking  it  before  it  was  finally  con- 
trolled. This  was  in  the  end  accomplished  by  a  tampon  in  the 
vagina  and  firm  compression  by  a  T  bandage. 

Causes. — The  great  predisposing  causes  are  pregnancy,  varicose 
condition  of  the  veins,  and  a  large  pelvic  tumor. 

The  exciting  causes  are  : — 

'  Obstet.  Works,  vol.  i,  p.  277,  Am.  ed. 


PUDENDAL    HEMATOCELE.  99 

Great  muscular  efforts  ;^ 
Blows  rupturing  the  labium ; 
Incisions  or  punctures. 

Symptoms. — The  hemorrhage  that  announces  the  accident  will 
lead  to  a  physical  exploration,  which  will  at  once  reveal  the  nature 
of  the  lesion. 

Treatment. — The  nature  of  the  accident  being  once  recognized, 
the  control  of  the  flow  will  not  usually  be  difficult.  If  it  be  not 
effected  by  cold  and  astringents,  such  as  ice,  the  persulphate  of  iron, 
or  tannin,  the  vagina  should  be  filled  with  a  firm  tampon  of  cotton, 
a  folded  towel  applied  as  a  compress  over  the  vulva,  and  a  T  band- 
age made  to  press  this  forcibly  against  the  body.  Should  this  plan 
fail,  the  wound  should  be  enlarged  by  incision  and  filled  with 
pledgets  of  cotton  saturated  with,  solution  of  persulphate  of  iron  ; 
then  the  tampon  should  be  applied  in  the  vagina  and  a  compress 
carefully  adjusted  by  means  of  a  T  bandage.  It  is  difficult  to  con- 
ceive of  any  case  occurring  in  the  non-pregnant  woman  which  could 
resist  this  method  if  effectually  em[)loyed. 

Pudendal  Hematocele. 

Definition  and  Synonyms. — The  term  thrombus,  derived  from  the 
Greek  Spo^^ow,  "  coagulate,"  and  which  is  used  synonymously  with 
hematoma  and  sanguineous  tumor,  is  that  which  is  generally  applied 
to  this  condition.  I  have  preferred  the  appellation  of  pudendal 
hematocele,  given  to  the  disorder  by  Dr.  A.  H.  McClintock,  from  its 
pointing  out  the  similarity  between  it  and  pelvic  hematocele, 
which  resembles  it  in  pathology,  and  because  the  term  thrombus  is 
now  commonly  applied  to  the  coagulation  of  blood  in  a  bloodvessel. 

A  pudendal  hematocele  is  a  tumor  formed  by  a  mass  of  clotted 
blood  eftused  into  the  tissue  of  one  labium,  or  the  areolar  tissue 
immediately  surrounding  the  wall  of  the  vagina. 

History. — As  early  as  1554,  the  disease  was  mentioned  by  Rueff, 
of  Zurich,  and  in  1647,  Yeslingius  is  said  by  Dr.  Merrimen  to  have 
noticed  it.  It  attracted  the  attention  of  Kronauer,  of  Basle,  in 
1734,  and  subsequently  that  of  Levret,  Boer,  Audibert,  and  others.^ 
In  time  it  passed  somewhat  out  of  notice,  until  the  researches  of 
Deneux,^  in  1830,  drew  attention  to  it  in  more  recent  times.  It  is 
generally  alluded  to  by  authors  only  as  one  of  the  results  of  preg- 


'  Prof.  Simpson  records  a  case  due  to  straining  at  stool. 

^  Velpeau,  Diet,  de  M6d.,  vol.  xxx. 

^  Sur  les  Tumeurs  sanguines  de  la  Vulve  et  du  Vagin. 


100  DISEASES    OF    THE    VULVA. 

nancy  and  parturition,  though  it  is  incontestably  proved  that  it  may 
occur  in  the  non-pregnant  and  even  in  the  virgin  state.  Velpeau 
records  an  instance  in  a  girl  of  fourteen  years,  who  had  not  yet 
arrived  at  puberty,  and  declares  as  the  result  of  his  experience,  that 
"thrombus  vulvae  occurs  almost  as  frequently  in  non-pregnant 
women  as  in  those  who  are  in  labor."  He  declares  that  he  has,  in 
the  course  of  one  year,  observed  six  cases  in  the  non-pregnant 
woman ;  and  in  his  whole  experience  he  has  met  with  twenty 
instances  of  the  affection. 

At  tbe  same  time  that  I  defer  to  the  statement  of  so  reliable  an 
authority  as  Velpeau,  I  must  exitress  surprise  at  it.  The  accident 
in  the  puerperal  woman  is  not  very  rare,  but  my  experience  would 
lead  me  to  regard  it  as  extremely  so  in  the  non-puerperal,  since  in 
a  practice  of  twenty-two  years  I  have  met  with  but  three  cases. 
These  occurred  as  direct  results  of  injuries  done  to  one  labium  by  a 
severe  blow,  and  resembled  very  closely  the  same  accident  which 
occurs  so  often  around  the  eye.  Another  fact  which  adds  to  my 
surprise  is  this;  in  connection  with  tliis  subject  I  have  carefully 
examined  the  current  njedical  literature  of  the  day,  and,  altliough 
it  teems  with  reports  of  this  affection  as  a  comjilication  or  sequel 
of  labor,  I  find  no  reports  of  instances  in  the  non-pregnant  woman. 
JSTevertheless,  as  I  am  in  this  work  strictly  avoiding  the  study  of 
the  diseased  states  constituting  the  complications  and  sequelae  of 
labor,  I  shall  specially  consider  that  form  of  the  affection  which 
occurs  in  the  non-puerperal  state. 

Pathology. — The  pathology  of  this  condition  is  similar  to  tliat  of 
pudendal  hemorrhage,  which  has  just  received  notice,  for  both  are 
results  of  rupture  of  the  bulbs  of  the  vestibule.  In  that  which  we 
are  now  considering  the  eff'used  blood,  instead  of  pouring  away, 
collects  in  the  tissue  of  one  labium,  under  the  vagina,  or  even  in  the 
areolnr  tissue  of  the  pelvis,  and  forms  a  coagulum.  It  bears  to 
pudendal  hemorrhage  the  same  relation  which  a  simple  fracture 
bears  to  one  of  compound  character. 

Rupture  of  a  branch  of  the  ischiatic  or  pudic  artery  may,  dur- 
ing labor,  likewise  produce  a  bloody  tumor,^  but  this  should  not  be 
treated  of  under  the  technical  head  of  pudendal  hematocele,  for  it 
would  really  constitute  a  case  of  sub-peritoneal  hematocele. 

Mode  of  Development.~W\\Q\\  a  large  vessel  has  been  injured,  a 
tumor,  perha[)S  tbe  size  of  an  orange,  is  suddenly  discovered  at 
the  vulva.     At  other  times  the  tumor  is  quite  small,  not  larger 


Meigs's  Treatise  on  Obstetrics,  5th  ed.,  p.  94. 


PUDENDAL    HEMATOCELE.  101 

than  a  walnut.  The  extent  of  the  laceration  likewise  governs 
the  rapidity  with  which  the  tumor  forms  after  the  injury  has  been 
inflicted.  In  some  instances  a  slight  flow  slowly  continues  until 
compression  from  the  clot  checks  it.  When  the  accident  occurs 
in  the  non-pregnant  state  the  amount  of  blood  effused  is  generally  less 
extensive  than  in  pregnancy,  and  is  usually  confined  to  the  vulva. 
Causes. — The  causes  are  similar  to  those  of  pudendal  hemorrhage, 
namely : — 

Muscular  eftbrts; 

Blows  injuring  the  labia ; 

Punctures  by  small  instruments. 

Symptoms. — The  symptoms  are  usually  a  sense  of  discomfort, 
with  pain  and  throbbing,  and  if  the  effusion  reaches  the  urethra, 
there  is  obstruction  to  urination.  The  patient  or  attendant  will 
often  first  recognize  the  fact  that  something  abnormal  has  occurred 
by  the  sense  of  touch,  practised  without  a  suspicion  as  to  the  nature 
of  the  real  difficulty. 

Differ eniiation.^ — Care  must  he  observed  not  to  confound  this 
affection  with — 

Abscess  of  the  labia ; 

Pudendal  hernia ; 

Inflammation  of  vulvo-vaginal  glands ; 

(Edema  labiorum. 

The  mere  announcement  of  the  possibility  of  error  in  diagnosis 
is  all  that  is  necessary,  for  the  physical  characteristics,  mode  of 
development,  and  rational  signs  of  these  affections  are  so  different 
from  those  of  pudendal  hematocele,  that  examination  will  always 
settle  the  point  with  certainty. 

Prognosis. — If  the  sanguineous  collection  be  small,  it  will,  espe- 
cially in  the  non-pregnant  state,  generally  disappear  spontaneously. 
If,  however,  it  be  large,  and  if  the  patient  have  recently  been  de- 
livered, there  are  always  two  dangers  to  be  apprehended.  The 
lesser  of  these  is  hemorrhage ;  the  greater,  purulent  infection 
through  tlje  vvalls  of  the  cyst,  or  the  formation  of  an  extensive 
abscess,  which  may  produce  the  same  result.  These  may  follow 
in  the  non-puerperal   form  of    the   affection,  but  the  danger   of 

'  I  have  ventured  to  use  this  term  in  place  of  "differential  diagnosis,"  giving  it 
the  signification  which  it  has  in  Natural  History,  instead  of  that  which  belongs  to 
it  in  Mathematics.  This  use  is  sanctioned  by  Worcester ;  and  Agassiz  speaks  of 
the  "differentiation  of  species."  Its  cognate  verb  is  equally  necessary  and  con- 
venient. 


102  DISEASES    OF    THE    VULVA. 

both  is  much  less  great  than  in  the  puerperal,  where  the  vessels  of 
the  part  are  largely  distended,  in  consequence  of  excessive  growth, 
and  where  the  blood  state  is  one  of  hjdrsernia  and  hyperinosis. 

Natural  Course. — Should  the  tumor  be  left  to  itself,  it  may  be 
absorbed  in  a  short  time  and  leave  no  trace  ;  in  five  or  six  days  it 
may  burst  and  discharge  ;  the  clot  may  become  encysted,  and  remain 
indefinitely  in  the  tissues ;  or  the  irritation  of  the  clot  may  create 
suppurative  inflammation,  and  abscess  of  the  labium  be  the  con- 
sequence. 

Treatment — Should  the  tumor  be  small,  and  not  excite  much 
pain,  a  cooling  lotion  of  lead  and  opium  should  be  applied,  the 
patient  kept  quiet,  and  the  evacuations  of  the  bladder  and  rectum 
regulated,  in  the  hope  that  absorption  will  take  place.  As  soon 
as  evidences  of  phlegmonous  inflammation  around  the  tumor  appear, 
suppuration  and  discharge  should  be  encouraged  by  poultices. 
When  the  tumor  is  large,  and  experiment  has  demonstrated  that  it 
will  not  undergo  absorption,  it  is  advisable  to  evacuate  the  blood- 
clot  by  incision.  This  should  be  done  by  means  of  a  bistoury,  upon 
the  mucous  face  of  the  labium  majus,  the  patient  being  placed  under 
the  influence  of  an  anaesthetic.  After  an  incision  has  been  made,  one 
finger  should  be  inserted  and  the  clot  turned  out  of  its  nidus.  If 
hemorrhages  ensue,  the  sac  should  be  thoroughly  washed  out  with 
a  solution  of  the  persulphate  of  iron,  and  pressure  exerted.  Should 
this  not  check  it,  pledgets  of  lint  soaked  in  this  astringent  should 
be  passed  into  the  sac,  and,  if  necessary,  counter-pressure  exerted 
per  vaginam  by  a  tampon  of  cotton.  In  case  no  hemorrhage  should 
follow  evacuation  of  the  cavity,  no  vaginal  tampon  should  be  em- 
ployed, nor  should  the  empty  sac  be  filled  with  cotton.  A  better 
plan  under  these  circumstances  would  be  to  wash  out  the  cavity 
thoroughly  with  a  weak  solution  of  carbolic  acid  in  water,  for  the 
more  certain  avoidance  of  septicaemia  and  of  plegmonous  inflam- 
mation. 

Pudendal  Hernia. 

Anatomy.— 'Ry  some  anatomists  it  is  stated  that  the  round 
ligaments  of  the  uterus  end  in  the  mons  veneris:  but  this  view 
is  probably  incorrect.  A  more  careful  dissection  traces  them 
through  the  internal  abdominal  rings,  along  the  inguinal  canals, 
to  the  labia  majora,  where  they  are  lost  in  the  dartoid  sacs,  de- 
scribed by  Broca  as  passing  through  these  folds.  The  labia  majora 
are  unquestionably  the  analogues  of  the  scrotum  of  the  male,  and 
the  round  ligaments  correspond  to  the  spermatic  cords. 


PUDENDAL    HERNIA.  10?) 

Definition. — Down  one  of  these  canals,  by  the  side  of  the  round 
ligament,  a  loop  of  intestine,  and  sometimes  a  portion  of  the  mes- 
entery, an  ovary,  or  even  the  bladder,  may  pass,  as  inguinal  hernia 
occurs  in  the  male. 

The  fact  that  this  disease  is  by  no  means  frequent,  makes  its 
recognition  the  more  important,  for  were  the  practitioner  not  aware 
of  the  possibility  of  its  occurrence,  the  intestine  might  be  wounded, 
under  the  supposition  that  the  labial  enlargement  was  due  to 
abscess,  or  distention  of  the  vulvo-vaginal  glands. 

Causes. — The  displacement  may  be  produced  by  violent  muscular 
efforts,  or  blows,  or  falls,  as  in  the  male. 

Symptoms. — Strangulation  of  the  intestine  with  its  characteristic 
signs  may  occur,  according  to  Sir  Astley  Cooper  and  Scarpa,^ 
although  it  is  very  rare.  The  hernia  may  usually  be  overcome  by 
taxis.  In  one  case  with  which  I  have  met,  reduction  was  ex- 
tremely difficult,  and  could  only  be  accomplished  by  prolonged 
effort.  When  the  intestine  becomes  prolapsed,  no  strangulation 
existing,  a  sense  of  discomfort,  upon  bending  the  body  or  even 
upon  walking,  directs  the  patient's  attention  to  the  affected  part, 
and  leads  her  to  apply  to  the  physician.  By  him  the  natui^e  of  the 
case  will  at  once  be  suspected,  from  the  peculiar  gaseous  or  airy 
sensation  yielded  to  the  touch.  Certainty  of  diagnosis  will  be 
arrived  at  by  absence  of  all  signs  of  inflammation  or  oedema,  the 
detection  of  impulse  upon  coughing,  and  resonance  upon  percus- 
sion, and  the  possibility  of  diminishing  the  volume  of  the  tumor 
by  taxis  and  position.  There  are  no  very  great  difficulties  attend- 
ing the  differentiation  of  the  disease.  The  danger  is  that  the  pos- 
sibility of  hernia  at  this  point  may  be  forgotten,  and  deductions 
drawn  without  considering  it.  Although  the  probability  of  error 
be  not  great,  the  appalling  nature  of  the  accident  in  which  it  would 
result,  warrants  the  relation  of  the  following  case,  which  is  illus- 
trative of  its  possibility.  A  patient  called  upon  me  with  the  follow- 
ing history:  she  had  had  an  abscess  just  below  the  external  ab- 
dominal ring,  which,  after  poulticing,  had  been  evacuated  by  her 
physician,  about  a  month  before  the  time  of  her  visit  to  me.  After 
this,  she  had  felt  well  until  a  week  before,  when,  after  a  muscular 
effort,  the  pain  had  returned  with  all  the  original  signs  of  abscess, 
and  these  had  continued,  although  she  had  painted  the  part  steadily 
with  tincture  of  iodine,  as  she  had  been  directed  to  do  in  case  of 
such  an  occurrence.     Being  in  great  haste  at  the  moment,  I  ex- 

'  Scanzoni,  op.  cit.,  p.  560. 


104  DISEASES    OF    THE    VULVA. 

amined  the  enlargement  while  the  patient  was  standing,  and  under 
a  recent  cicatrix,  which  was  painted  with  iodine,  I  discovered  what 
I  su[»posed  to  be  a  reaceumulation  of  pus.  As  the  patient  came  to 
me  in  the  absence  of  her  physician,  merely  for  the  evacuation  of 
this,  I  placed  her  in  the  recumbent  posture,  and,  lancet  in  hand, 
proceeded  to  operate.  But  to  my  surprise,  I  discovered  that  change 
of  posture  diminished  the  size  of  the  enlargement.  This  excited 
my  suspicions,  and  I  found  that  a  recent  hernia  had  occurred  under 
the  old  cicatrix. 

Treatmeyit. — The  patient  having  been  placed  upon  the  back  with 
the  hips  elevated  by  a  large  cushion,  or,  as  is  better,  by  elevation  of 
the  foot  of  the  bed  or  table  upon  which  she  lies,  the  tumor  should 
be  grasped,  compressed,  and  pushed  up  the  canal,  down  which  it 
has  descended,  until  it  returns  to  the  abdomen.  Then  a  truss,  so 
arranged  as  to  press  upon  the  inguinal  canal,  should  be  adjusted, 
and  worn  with  a  perineal  strap,  to  keep  the  compress  of  the  instru- 
ment sufficiently  low  down  to  eiFectually  close  the  point  of  exit. 
Should  strangulation  have  occurred,  and  return  of  the  prola[ised 
part  by  taxis  prove  impossible,  the  case  will  require  the  surgical 
operation  for  that  condition,  for  a  description  of  which  the  reader 
is  referred  to  works  on  general  surgery. 

Hydrocele. 

Definition  and  Frequency. — This  affection,  which  consists  in  a 
collection  of  fluid  in  the  inguinal  canal,  around  the  round  liga- 
ment, is  one  of  such  rarity  in  the  female  that  its  very  existence  is 
commonly  ignored,  and  mention  of  it  is  rarely  made  by  systematic 
writers.' 

Anatomy. — It  has  been  already  stated  that  the  labia  majora 
of  the  female  are  analogous  to  the  scrotum  of  the  male,  and  that 
the  round  ligaments,  which  are  analogous  to  the  spermatic  cords, 
do  not  end  in  the  mons  veneris,  as  was  formerly  supposed,  but 
yiassing  downwards  enter  the  labia  majora  and  distribute  their 
filaments  within  the  dartoid  sacs,  which  extend  like  glove-fingers 
downwards  towards  the  fourchette.  The  interesting  and  valuable 
article  of  M.  Broca  upon  this  subject  will  be  found  quoted  at 
length  in  Cruveilhier's  Anatomy.  The  peritoneal  covering  of  these 
ligaments  usually  extends  to  the  inguinal  canals,  but  occasionally 
in  young  subjects  it  is  prolonged  through  a  portion  of  the  canal  con- 
stituting the  canal  of  N"uck.2    In  adults  this  is  ordinarily  obliter- 

'  Scanzoni's  work  upon  Diseases  of  Women  contains  an  account  of  it. 
2  Cyi-lopcdia  of  Anat.  and  Phys.,  Supplement,  p.  706. 


HYDROCELE.  105 

ated,  and  hence  the  rarity  of  hydrocele  and  hernia  in  the  female. 
Sometimes  it  remains  permanently  open,  when  not  only  may  the 
intestines  descend,  but  even  the  ovary  may  pass  down,  making  an 
attempt  to  enter  the  dartoid  sacs  and  imitate  the  entrance  of  the 
male  testes  into  the  scrotum. 

Pathology. — The  affection  which  we  are  now  considering,  is 
probably  the  result  of  excessive  secretion  on  the  part  of  this  serous 
membrane,  which,  by  the  fluid  collected  within  it,  is  distended 
laterally  and  downwards.  Should  the  abdominal  opening  of  such 
a  sac  remain  pervious,  the  fluid  thus  collecting  could  readily  be 
forced  upwards  as  in  the  same  affection  in  the  male,  but  if  that 
opening  has  become  impervious,  the  fluid  becomes  sacculated  and 
such  return  is  impossible.  So  rare  is  this  affection  that  I  offer  no 
apology  for  the  introduction  of  the  following  instance  of  it,^  re- 
ported by  Dr.  E.  P.  Bennett,  of  Danbury,  Connecticut. 

"  In  an  extensive  practice  of  over  forty  years,  but  one  single  case  has 
come  under  my  observation.  This  case  occurred  recently  in  a  young 
married  female  residing  in  Putnam  County,  and  was  mistaken  by  a  sur- 
geon of  some  eminence  for  a  case  of  inguinal  hernia,  who  endeavored 
to  reduce  it,  but  foiling  to  do  so,  pronounced  it  adherent,  and  irreducible, 
and  advised  to  let  it  alone.  That  such  a  mistake  should  have  been 
made  is  not  at  all  surprising,  as  it  was  a  h3^drocele  of  the  round  liga- 
ment coming  down  through  the  inguinal  canal,  and  occupying  exactly 
the  place  of  inguinal  hernia,  and  closely  resembling  one.  She  subse- 
quently came  under  m_y  care,  and  upon  inquiry  I  learned  that  about 
live  years  since  a  small  tumor  had  made  its  appearance,  which  had 
slowly  and  steadily  increased  in  size  until  it  had  attained  its  present 
size,  which  was  about  as  large  as  a  turkey's  egg.  It  had  not  been  pain- 
ful, was  not  attended  with  abdominal  disturbance,  had  never  receded 
when  decumbent,  and  gave  to  the  touch  a  feeling  of  fluid  contents 
instead  of  the  doughy  feel  of  hernia,  and  I  therefore  thought  that, 
whatever  it  might  be,  it  was  not  hernia ;  and,  upon  closer  inspection,  I 
diagnosed  hydrocele  of  the  round  ligament,  although  it  was  not  diapha- 
nous. So  sure  was  I  of  a  correct  diagnosis  that  I  at  once  proposed  an 
oi^eration,  to  which  she  readily  consented ;  and,  with  the  aid  of  a  pro- 
Icssional  brother,  who  coincided  with  me  in  my  diagnosis,  I  proceeded 
v<)  cautiously  lay  open  the  sac,  when  we  found,  to  our  great  satisfaction, 
that  we  had  not  blundered  in  our  opinion.  The  serous  contents  of  the 
sac  having  been  evacuated,  I  injected  it  with  a  saturated  tincture  of 
i(xline,  and  she  speedily  recovered  without  the  supervention  of  a  single 
unpleasant  symptom.     This  case  is  only  important  from  its  rarity,  and 

•  N.  Y.  Med.  Record,  Nov.  15,  1870. 


106  DISEASES    OF    THE    VULVA. 

the  fact  that  most  physicians  are  not  aware  that  hydrocele  can,  or  ever 
does,  occur  in  the  female ;  and  my  object  in  writing  this  article  is  not 
to  record  any  remarkable  achievement  in  surgery,  but  to  call  the  atten- 
tion of  physicians  to  this  subject,  and  thereby  prevent  mistalies  which 
might  be  attended  with  disastrous  results." 

A  pamphlet  has  recently  appeared  upon  the  subject  by  Dr.  Hart 
of  this  city.  In  it  he  details  an  operation  for  hernia  performed  in 
a  case  of  hydrocele  from  a  mistake  in  diagnosis.  The  fluid  of  the 
hydi-ocele  being  evacuated,  the  wound  was  closed  by  silver  suture, 
and  tlie  patient  recovered.  He  declares  that  the  disease  is  mentioned 
by  ^tius,  Far^,  Scarpa,  Meckel,  and  Poland. 

Differentiation. — The  greatest  circumspection  should  be  observed 
before  a  diagnosis  of  this  rare  malady  is  arrived  at.  The  sense  of 
fluctuation,  with  entire  absence  of  symptoms  of  inflammation, 
the  absence  of  resonance  on  percussion,  and  the  ordinary  signs  of 
hernia,  the  existence  of  translueency,  and  the  gradual  development 
of  the  tumor  without  pain  or  constitutional  excitement,  would  all 
be  reasons  for  suspecting  it.  But,  before  ultimate  measures  are 
adopted  for  its  cure,  a  very  fine  exploring  needle,  such,  for  exam- 
ple, as  that  of  the  ordinary  hypodermic  syringe,  shi^uld  be  passed  in, 
in  order  that  the  contents  of  the  sac  may  be  carefully  examined. 

Should  the  character  of  this  fluid  not  assure  us  that  hernia  exists, 
the  smallest  needle  of  the  aspirator  should  be  introduced,  and  all 
the  fluid  drawn  off.  Even  where  hernia  exists,  such  a  procedure 
has  been  found  to  favor  return  of  the  sac,  and  to  do  no  harm  by 
rendering  it  subsequently  pervious. 

Treatment. — The  diagnosis  being  made,  the  treatment  should 
consist  in  evacuation  by  means  of  the  aspirator,  and,  if  cure  do  not 
follow  this,  in  the  injection  of  tincture  of  iodine  in  addition,  which 
may  be  done  by  reversing  the  action  of  the  same  instrument. 

Pruritus  Vulvae. 

Definition. — This  affection  consists  in  irritability  of  the  nerves 
su[iplying  the  vulva,  which  induces  the  most  intense  itching  and 
desire  to  scratch  and  rub  the  parts.  Although  not  itself  a  disease, 
it  is  alw\ay8  so  important,  and  often  so  obscure  a  symptom,  that  it 
requires  special  notice  and  investigation. 

Pathology. — It  has  just  been  stated  that  it  consists  in  disorder  of 
the  nerves  supplying  the  vulva.  It  matters  not  whether  this  be  a 
true  neurosis  or  one  secondary  to  some  other  pathological  state,  the 
great  element  of  pruritus  vulvae  is  nervous  irritability  or  hyper?es- 
thesia.     That  it  is  often  excited  by  irritating  discharges  and  erup- 


PRURITUS    YVhYM.  107 

tive  disorders  there  can  be  no  question.     Whether  it  ever  depends 
upon  idiopathic  nervous  hypereesthesia,  as  some  suppose,  is  doubtfuh 
I  have  never  met  with  an  instance  in  which  it  appeared  to  do  so. 
Mode  of  Development  and  Course. — In  the  beginning,  the  irrita- 
ll  bility  and  tendency  to  scratch  are  sometimes  very  slight,  so  as  to 
la  annoy  the  patient  very  little  and  give  her  but  trifling  uneasiness. 
J  Sometimes  they  exist  only  after  exertion  in  warm  weather,  upon 
K  exposure  to  artificial  heat,  or  just  before  and  after  menstruation. 
';  The   disorder   is  aggravated   by    the   counter-irritation    which    it 
(  demands  for  its  relief.     The  rubbing  and  scratching  that  are  prac- 
t  tised   cause   an   afilux   of   blood,  render  the  skin  tender  and  its 
nerves  sensitive,  and  in  time  greatly  augment  the  evil  by  pro- 
t  ducing  a  papular  eru[)tion.     The  disease  and  the  remedy  which 
instinct  suggests,   react   upon  each  other,  the  first  requiring  the 
second,  and  the  second  aggravating  the  first,  until  a  most  rebellious 
sand  deplorable  condition  is  developed.      It  would  be  diflicult  to 
exaggerate  the  misery  in  some  of  these  cases.    The  patient  is  bereft 
of  sleep  by  night,  and  tormented  constantly  by  day,  so  that  society 
I  becomes  distasteful  to  her,  and  she  gives  way  to  despondency  and 
depression.     The  itching  is  generally  intermittent,  in  some  cases 
occurring  at  night,  in  others  only  at  certain  periods  of  the  day. 
In  two  cases  that  I  have  met,  the  patients  were  free  from  all  irri- 
tation except  at  night,  when  the  disturbance  and  nervous  anxiety 
became  so  intense  as  to  prevent  sleep,  except  when  large  doses  of 
opium    were   given.     Loss   of  sleep,  the    use   of  opium,  and  the 
nervous  disturbance  incident  to  the  disease,  often  prostrate  and 
*  exhaust  the  patient  to  an  astonishing  extent. 

This  disorder  is  to  some  degree  paroxysmal,  any  influence 
which  produces  congestion  of  the  genital  organs  aggravating  it 
\very  much.  Lying  in  a  warm  bed,  sexual  intercourse,  eating  and 
t  drinking,  more  especially  highly  seasoned  food  and  stimulating 
\  beverages,  and  the  act  of  ovulation,  all  produce  this  result.  Its 
duration  has  no  limit,  months,  and  even  years,  sometimes  passing 
I  before  relief  is  obtained. 

Although  the  term  "  pruritus  vulvae"  is  that  ordinarily  applied 
to  it,  it  nmst  not  be  supposed  that  the  irritation  is  always  confined 
to  the  vulva.  It  often  extends  up  the  vagina,  to  the  anus,  and 
<  down  the  tiiighs.  In  pregnant  women  I  have  repeatedly  known  it 
1  to  spread  over  the  abdomen.  It  may  be  asked  why  such  a  state 
should  be  styled  "  pruritus  vulvfe?"  These  extensions  are  merelj' 
complications  of  the  original  malady  which  really  deserves  that 


108  DISEASES    OF    THE    VULVA. 

name,   and   are   due   to   contamination,  by   scratching,   with   an  j 
ichorous  element  which  constitutes,  as  I  believe,  the  prominent  ex- 
citing cause  of  the  trouble. 

Causes. — Every  practitioner  dreads  to  meet  with  an  aggravated 
case  of  })ruritus  vulvae,  for  he  knows  how  obstinate  the  malady 
commonly  i)roves.  The  only  reasonable  hope  of  controlling  it  must 
rest  in  viewing  it  strictly  as  a  symptom,  and  striving  to  discover 
and  remove  its  cause.  iN'o  fixed  prescriptions,  however  much  lauded 
for  their  efficacy,  should  be  relied  upon.  The  primary  disorder 
should  be  sought  for  and  cured,  in  the  hope  of  removing  that  one 
of  its  results  which  is  most  [pressing  in  its  demands  for  relief. 
Should  the  case  have  progressed  for  some  time,  it  will  often  be 
found  impossible  to  decide  as  to  its  cause,  for  the  scratching  induced 
by  it  will  frequently  establish  a  cutaneous  disorder,  the  connec- 
tion of  which  with  the  pruritus,  whether  as  cause  or  effect,  will  be 
doubtful. 

The  predisposing  causes  of  pruritus  are  the  following  : 

Uterine,  vaginal,  or  urethral  disease; 

Pregnancy ; 

Depreciated  general  health ; 

Habits  of  indolence,  luxury,  or  vice ; 

Uterine  or  abdominal  tumors ; 

Want  of  cleanliness  ; 

Constitutional  syphilis ; 

Severe  exercise  in  one  of  sedentary  habits. 

It  will  be  observed  that  most  of  these  influences  are  those  which 
predispose  to  the  development  of  abnormal  secretion  by  the  mucous 
membrane  lining  the  genital  tract.  Such  excessive  and  deranged 
secretion  I  believe  to  be  in  the  great  majority  of  cases  the  imme- 
diate, exciting  cause  of  the  nervous  irritation.  That  there  are  other 
causes,  it  will  be  seen  that  I  admit,  but  to  treat  this  condition  suc- 
cessfully, I  am  convinced  that  special  reference  must  be  had  to  this 
element.  He  who  simply  keeps  in  view  the  local  trouble,  in  the 
majority  of  cases  will  be  striving  merely  against  the  branches  of 
an  evil,  the  root  of  which  consists  in  the  ichorous  material,  which 
bathes  and  excoriates  the  terminal  extremities  of  the  nerves  of  the 
vulva  and  vagina. 

In  all  the  instances  of  pruritus  vulvae  that  I  have  been  able  to 
examine  early  enough  to  determine  as  to  the  etiology,  I  have  found 
one  of  the  following  conditions  to  exist  as  the  apparent  cause  of  the 
hypersesthetic  condition  of  the  nerves : 


J'UL'UITUS    VULV^.  109 

1st.  Contact  of  an  irritating  discharge — 
Leucorrhoea  ; 
Hydrorrhoea, ; 
Discliarge  of  cancer; 
Dribbling  of  urine; 
Diabetes. 

2il.  Local  inflararfiation — 
Vulvitis ; 
Uretbritis ; 
Vaginitis  ; 
Aphthous  ulcers. 

2)d.  Local  irritation — 

Eruptions  on  the  vulva  ; 

Animal  parasites ; 

Onanism ; 

Vegetations  on  the  vulva  ; 

Vascular  urethral  caruncles ; 

Growth  of  short  bristly  hair  on  mucous  face  of  labia. 

Of  all  these,  leucorrhcea  is  the  most  frequent  cause.  This  symptom 
of  uterine  disorder  fortunately  produces  pruritus  only  as  an  excep- 
tion to  a  rule.  Under  certain  circumstances  it  appears  to  possess 
jieculiarly  irritating  and  excoriating  qualities,  which,  even  when 
the  flow  is  insignificant  in  amount,  will  excite  the  most  intolerable 
itching.  This  feature  is  most  commonly  observed  in  the  discharge 
attending  pregnancy;  and  in  that  of  senile  endometritis,  which 
covers  the  vagina  with  bright  red  spots,  and  gives  it  a  glazed  look 
like  serous  membrane.  In  an  exceedingly  obstinate  case,  occurring 
in  a  woman  of  seventy  years,  tbe  leucorrhoeal  discharge  was  so 
small  in  amount  that  the  patient  was  not  aware  of  its  existence, 
nor  did  I  appreciate  its  connection  with  the  disorder  until  I  dis- 
covered accidentally  that  the  only  relief  which  could  be  obtained 
followed  the  application  of  a  wad  of  cotton  against  tbe  cervix 
uteri.  In  every  case  of  pruritus  the  vagina  should  be  carefully  in- 
vestigated for  evidence  of  leucorrhoea,  unless  some  other  sufficient 
cause  is  apparent.  In  the  same  manner  the  other  discharges  men- 
tioned may  cause  nervous  irritability  in  the  vulva. 

It  is  not,  however,  usually  vaginal  leucorrhoea  which  produces 
the  result,  it  is  much  more  commonly  due  to  the  discharge  arising 
from  cervical  or  corporeal  endometritis,  and  the  obstinacy  of  these 
aftections  accounts  to  some  extent  for  that  of  tlje  secondary  one. 


110  DISEASES    OF    THE    VULVA. 

I  have  so  often  found  diabetes  accompanied  by  this  symptom  that 
I  always  examine  the  urine  in  obscure  cases.  It  is  by  many  attri- 
buted to  the  constitutional  agency  of  the  disease.  The  marked 
relief  afforded  by  the  systematic  use  of  the  catheter,  has  led  me  to 
think  otherwise.  My  impression  is  that  the  pruritus  is  probably 
not  connected  with  the  constitutional  effects  of  the  disease  upon  the 
nerves,  but  with  the  direct  and  local  influence  exerted  by  the  dis- 
ordered secretion. 

Local  inflammation,  by  the  discharge  which  it  excites  and  the 
itching  which  attends  it,  is  very  evidently  calculated  to  give  rise 
to  pruritus  ;  and  yet  cases  thus  established  are  not  the  most  rebel- 
lious with  which  we  meet. 

Any  form  of  eruption  upon  or  around  the  vulva  may,  and  usually 
does,  excite  itching.  Eczema,  prurigo,  lichen,  and  many  others, 
may  do  so  here  as  they  do  elsewhere,  and  the  natural  warmth  of 
the  part,  formed  as  it  is  of  folds  of  tissue  and  covered  by  hair  which 
is  thickly  interspersed  with  sebaceous  and  piliferous  glands,  makes 
them  the  more  likely  to  prove  active  in  causing  it. 

Animal  parasites  of  two  varieties  may  give  rise  to  it,  the  pedic- 
ulus  pubis  and  the  acarus  scabiei.  The  first  excites  through  irrita- 
tion a  lichenoid  eruption,  while  the  second  produces  scabies,  or 
itch. 

One  of  these  causes  will  generally  be  found  to  have  given  rise  to 
pruritus  vulvte,  but  it  is  only  in  originating  the  difiiculty  that  it 
will  prove  active.  Very  soon  secondary  influences,  as  eruptions, 
excoriations,  ulcerations,  and  increased  discharges,  the  results  of 
scratching,  superadd  themselves  as  auxiliary  agents,  and  keep  up 
the  disorder. 

Treatment. — It  has  been  stated  that  the  first  effort  of  the  prac- 
titioner should  always  be  to  discover  the  disease  of  which  the 
pruritus  is  a  symptom,  and  then  to  endeavor  to  remove  it  by  ap- 
propriate means.  Should  leucorrhoea  be  the  cause,  the  uterine  or 
vaginal  aftection  which  gives  rise  to  it  should  be  treated.  Should 
an  eruptive  disorder  be  found  to  be  the  source  of  the  difficulty, 
the  measures  which  would  be  advisable  for  this  affection  elsewhere 
developed,  laxatives,  baths,  change  of  air,  tonics,  and  arsenic,  would 
be  equally  beneficial  here. 

But  this  alone  will  not  be  sufficient.  While  eradication  of  the 
mischief  is  thus  attempted,  palliative  means  must  be  vigorously 
adopted  for  the  sake  of  present  relief.  Should  the  case  be  regarded, 
upon  careful  investigation,  as  due  to  contact  of  an  irritating  fluid 
with  the  nerves  of  the  vulva,  perfect  cleanliness  should  be  secured 


PRURITUS    VULV^.  Ill 

by  three,  four,  or,  if  necessary,  a  larger  number  of  sitz  baths  daily 
and  the  vagina  should,  at  tiie  time  of  taking  each  bath,  be  syringed 
out  with  pure  or  medicated  water.  The  irritated  surface  should 
bo  protected  by  unctuous  substances,  or  inert  powders,  such  as  bis- 
muth, lycopodium,  or  starch,  from  the  injurious  contact,  and  in 
case  the  discharge  comes  from  the  uterus,  a  wad  of  cotton  should 
he  placed  daily  against  the  cervix  uteri  to  prevent  its  escape  to  the 
vulva,  or,  as  is  better,  after  a  thorough  use  of  the  vaginal  douche 
the  vagina  should  be  thoroughly  tamponed  daily  with  cotton  satu- 
rated with  glycerine  to  which  has  been  added  borax  or  acetate  of 
lead,  two  drachms  to  the  ounce.  Of  this  plan,  which  I  should 
mention  does  not  confine  the  patient  to  bed,  I  can  speak  in  high 
terms.  While  it  protects  the  vulva  from  ichorous  discharges,  it 
does  not  j^revent  ablution  and  applications  to  the  point  of  maxi- 
mum irritation.  A  very  useful  vaginal  injection,  and  wash  for  the 
vulva,  under  these  circumstances,  is  the  following : 

R. — Plnmbi  acetatis,  ^iv. 
Acidi  carbolici,  ^ij. 
Tr.  opii,  5iv. 
Aqua2,  Oiv. — M. 

This  may  relieve  itching  for  a  time,  until  removal  of  the  cause 
of  the  symptom  is  accomplished. 

In  case  the  pruritus  is  the  result  of  a  local  inflammation,  this 
should  be  treated  as  elsewhere  recommended,  by  poultices  of  lin- 
seed, potato,  or  slippery  elm,  to  which  have  been  added  a  proper 
amount  of  lead  and  opium;  or  fomentations  of  lead  and  opium 
wash,  or  poppy-heads  may  be  used  in  tlieir  stead.  If  vaginitis  or 
vulvitis  be  present,  great  relief  will  often  be  obtained  by  painting 
the  lining  membrane  of  tlie  diseased  part  over  with  a  strong  solu- 
tion of  nitrate  of  silver,  or  by  touching  the  whole  surface  very 
lightly  with  the  solid  stick,  and  then  using  the  tampon  of  cotton 
and  glycerine. 

Sliould  an  eruptive  disorder  be  the  exciting  cause,  it  should,  as 
already  stated,  be  treated  upon  general  principles.  Meantime 
temporary  relief  may  be  obtained  by  painting  the  surface  of  the 
vulva  over  with  a  solution  of  nitrate  of  silver  (9j  to  ^j),  the  use  of 
the  ungt.  creasoti,  ungt.  chloroformi,  or  ungt.  atropise  of  the  U.  S. 
Dispensatory.  Dr.  Simpson  advises  an  infusion  of  tobacco,  and 
Dr.  J.  C.  Osborn,'  of  Alabama,  in  an  interesting  article  upon  the 
medicinal  use  of  this  drug,  declares  that  he  always  resorts  to  a 

'  N.  0.  Med.  and  Surg.  Journal,  Nov.  1866. 


112  DISEASES    OF    THE    VULVA. 

strono-  decoction  of  it  as  a  wash  for  the  vagina  and  vulva  in  thi.i 
affection,  and  for  the  anus  in  "prurigo  podicis."  According  to 
the  hitter  gentleman  the  local  sedative  effects  of  tobacco  are  very 
useful  in  the  control  of  prurigo.  My  own  experience  agrees  with 
his. 

Although  the  feet  will  probably  not  prove  one  of  practical  value, 
it  is  certainly  one  of  interest  that  cases  have  recently  been  reported 
in  which  smoking  tobacco  has  appeared  to  relieve  pruritus.  Ao 
an  illustration  I  quote  the  following:  "Mrs.  W.,^  a  woman  of 
nervous  temperament,  became  pregnant  a  few  months  after  her 
marriage.  In  addition  to  the  usual  derangement  of  the  alimentary 
canal,  she  soon  experienced  a  severe  itching  all  over  her  body. 
The  skin  was  of  a  perfectly  normal  appearance ;  the  pruritus,  how- 
ever, caused  her  great  excitement  and  soon  produced  nervous 
spasms.  For  several  weeks  every  possible  external  and  internal 
remedy  was  used  in  vain.  A  decoction  of  walnut  leaves  gave  her 
some  relief  when  in  the  seventh  month  of  pregnancy.  Then  a 
violent  pyrosis  and  neuralgia  of  the  dental  nerves  supervened. 
In  order  to  alleviate  the  latter,  she  was  advised  by  her  husband  to 
try  the  effect  of  smoking,  when  the  pain  as  Avell  as  the  itching  and 
pyrosis  disappeared  immediately.  jMrs.  W.  smoked  one  cigar 
every  evening  until  she  was  prematurely  delivered  by  a  fright, 
after  8|-  months. 

"  Fourteen  months  afterwards,  JMrs.  W.  again  became  pregnant, 
and  was  again  affected  in  the  fourth  month  of  pregnancy  with 
pruritus  followed  by  pyrosis.  She  did  not  immediately  resort  to 
smoking,  from  the  dislike  of  this  habit,  until  the  evil  increased, 
when  the  smoking  of  one  cigar  again  rendered  her  perfectly 
comfortable." 

No  local  application  has  acquired  a  more  universal  popularity  in 
the  treatment  of  pruritus  vuIvjb  than  solutions  of  corrosive  subli- 
mate.    The  following  formula  is  a  good  one  of  its  kind: 

R. — Hydrarg.  bichloridi,  gss. 

Tr.  opii.  Ij. 

Aquae,  5vij. — At. 
S.  For  external  use  only. 

Should  eczema  or  lichen  have  produced  inflammatory  action  in 
the  skin  and  subcutaneous  areolar  tissue,  poultices,  etc.,  should  be 
employed,  as  if  local  inflammation  were  the  cause  of  the  affection. 

While  these  palliative  and  curative  means  are  being  adopted, 


Tribune  Med.,  Jan.  31,  1869 ;  Wiener  Med.  Woclienschrift,  No.  22,  1869. 


r 


PRURITUS    VULVAE.  113 

sleep  should  be  secured  by  preparations  of  opium,  or  one  of  its 
substitutes,  codeine,  chloral,  hyoscjamus,  or  ehlorodyne.  At  the 
same  time  the  general  state  of  the  patient  should  be  improved  by 
vegetable  and  mineral  tonics,  good  food,  and  fresh  air.  In  some 
cases  more  benefit  will  arise  from  the  use  of  iron,  the  mineral 
acids,  and  sea-bathing,  tlian  from  any  other  means. 

In  certain  cases  dependent  upon  chronic  vaginitis,  or  chronic 
endometritis  which  has  resulted  in  vaginitis,  the  disorder  will  be 
found  to  be  rather  "pruritus  vaginte"  than  "pruritus  vulvse,''  and 
under  these  circumstances  the  severity  of  the  local  and  general 
disturbance  may  be  very  great.  In  such  cases  I  have  found  great 
benefit  from  the  frequent  use  of  copious  vaginal  injections  of  warm 
infusion  of  bran.  The  patient,  in  the  semi-recumbent  posture, 
with  the  nates  over  a  tub  containing  three  or  four  quarts  of  this, 
with  from  six  to  eight  drachms  of  laudanum,  and  one  to  two 
drachms  of  acetate  of  lead  dissolved  in  it,  should  inject  the  vagina 
freely  for  from  ten  to  fifteen  minutes,  and  this  should  be  rejteated 
four  or  five  times  a  day.  After  a  short  time  the  soothing  and 
alterative  influence  which  it  exerts  will  show  itself  so  decidedly 
that  less  assiduous  attention  to  the  disorder  will  be  demanded. 

In  the  same  way  infusion  of  tobacco  and  solutions  containing 
borax,  lead,  alum,  zinc,  or  carbolic  acid  will  be  found  to  be  very 
valuable  remedies.  They  sliould  be  used  very  freely,  and  after 
previous  cleansing  of  the  vagina  by  pure  water.  One  great  difii- 
culty  in  the  treatment  of  the  disease  consists  of  the  inefiicient 
manner  in  which  vaginal  injections  are  practised  by  patients. 
This  should  be  guarded  against  by  explicit  directions,  and  the  use 
of  the  means  suggested  hereafter  in  connection  with  that  subject. 

The  following  prescriptions  have  obtained  a  reputation  lor  the 
treatment  of  pruritus;  and, I  know  by  experience  that  they  de- 
serve it : 

R. — Cliloroformi,  5]. 

01.  amygdalarnm,  3J. — M. 
S.  Apply  to  vulva  anJ  outlet  of  vagina. 

R. — Acidi  hydrocyan.  dil.  gij. 
Plumbi  diacetati,  9j. 
Olei  cacao.  5ij. — M. 
S.  Apply  after  wapliing  with  cold  water. 

R. — Ijotionis  niirri,  Oj. 
SodiE  biborat.  5J. 
Morphias  sulphat.  gr.  x. — M, 
S.  Apply  after  bathing  the  part. 


1|4  DISEASES    OF    THE    VULVA. 

R. — Acidi  tannici,  gr.  c. 
Belladounse  ext.,  gr.  x. 
Butyr.  cacao,  q.  s. 
M.  et  ft.  supposit.  vag.  xx. 
S.  Let  the  patient  place  one  in  contact  with  the  cervix  uteri,  every  night,  after 
thoroughly  syringing  the  vagina. 

Where  diabetes  exists  as  a  cause  the  patient  sliould  bathe  the 
parts  after  urination,  and  be  instructed  to  keep  the  vulva  thor- 
oughly covered  and  protected  by  one  of  the  ointments  already 
mentioned. 

Where  the  pediculus  pubis  is  found  to  exist,  mild  mercurial 
ointment  should  be  applied ;  and  for  the  acarus  scabiei,  sulphur 
ointment  will  be  found  quite  sufficient  as  a  parasiticide. 

The  following  prescription  I  have  never  employed,  but  it  is 
highly  recommended  by  good  authority: 

R. — Zinci  sulphur-carbokit.  5j. 
Aqna3  destillat.  §ij. 
S.  After  careful  bathing,  use  as  a  wash  once  or  twice  a  day. 

Where  short,  bristly  hairs  are  found  growing  from  the  inner  or 
mucous  surface  of  the  labia  majora,  great  relief  follows  depilation. 
Each  hair  should  be  seized  by  forceps,  the  operator  using  a  magni- 
fying glass,  and  jerked  from  its  i)lace. 

A  revicAV  of  the  plans  of  treatment  here  given  will  convince  the 
reader  that  they  are  all  based  upon  the  recognition  of  the  causa- 
tive lesion.  jSTo  disorder  is  more  inappropriate  for  empirical  treat- 
ment. 

Hyperaesthesia  of  the  Vulva. 

Definition. — The  disease  which  I  proceed  to  describe  under 
this  name,  although  to  all  appearances  one  of  trivial  character, 
really  constitutes,  on  account  of  its'  excessive  obstinacy  and  the 
great  influence  which  it  obtains  over  the  mind  of  the  patient,  a 
malady  of  a  great  deal  of  importance.  It  consists  in  an  excessive 
sensibility  of  the  nerves  supplying  the  mucous  membrane  of  some 
portion  of  the  vulva ;  sometimes  the  area  of  tenderness  is  confined 
to  the  vestibule,  at  other  times  to  one  labium  minus,  at  others  to 
the  meatus  urinarius ;  and  again  a  number  of  these  parts  may  be 
simultaneously  aflfected.  It  is  a  condition  of  the  vulva  closely 
resembling  that  hypersesthetic  state  of  the  remains  of  the  hymen 
which  constitutes  one  form  of  vaginismus.  In  two  cases  I  have 
seen  the  whole  surface  of  the  vulva,  except  the  labia  majora, 
aflfected  by  an  excessive  sensibility  which  extended  along  the 
urethra. 


HYPERiESTHESIA     OF    THE    VULVA.  116 

Frequency. — This  disorder,  altliougli  fortunately  not  very  frequent, 
is  by  no  means  very  rare.  So  commonly  is  it  met  with  at  least, 
that  it  becomes  a  matter  of  surprise  that  it  has  not  been  more 
generally  and  fully  described. 

Pathology. — It  is  not  a  true  neuralgia,  but  an  abnormal  sensitive- 
ness ;  "  a  plus  state  of  excitability"  in  the  diseased  nerves.  No 
inflammatory  action  affects  the  tender  surface,  no  pruritus  attends 
the  condition,  and  physical  examination  reveals  nothing  except 
occasional  spots  of  erythematous  redness  scattered  here  and  there. 
The  nerve  state  appears  identical  with  that  which  sometimes  de- 
velops in  the  scalp,  and  on  parts  of  the  cutaneous  surface.  The 
slightest  friction  excites  intolerable  pain  and  nervousness ;  even  a 
cold  and  unexpected  current  of  air  produces  discomfort ;  and  any 
degree  of  pressure  is  absolutely  intolerable.  For  this  reason  sexual 
intercourse  becomes  a  source  of  great  discomfort,  even  when  the 
ostium  vaginse  is  large  and  free  from  disease.  It  is  this  difficulty 
which  generally  first  causes  the  patient  to  apply  to  a  physician  for 
relief. 

Causes. — The  predisposing  causes  aj)pear  to  be  the  period  of  life 
near  or  at  the  menopause,  the  hysterical  diathesis,  or  a  morbid 
mental  state  characterized  by  tendency  to  depression  of  spirits. 
As  exciting  causes  I  have  found  chronic  vulvitis  and  irritable 
urethral  tumors  to  exist  in  some  cases,  but  in  others  no  cause  what- 
ever has  been  apparent. 

Symptoms. — I  have  said  so  much  on  this  subject,  under  the  head 
of  definition,  that  I  have  little  more  to  add.  The  f)atient  applies 
for  relief  because  the  act  of  sexual  intercourse  is  painful,  and  be- 
cause in  the  sensitive  spot  there  is  always  a  degree  of  discomfort, 
which  is  increased  by  bathing  the  part,  or  even  by  the  friction 
incident  to  walking.  Upon  questioning  her,  it  will  be  observed 
that  her  mind  is  disproportionately  disturbed  and  depressed  by 
this.  In  some  cases  it  seems  to  absorb  all  the  thoughts,  and  to 
produce  a  state  bordering  upon  monomania. 

Differentiation. — It  should  be  distinguished  from  irritable  urethral 
tumor  and  vaginismus,  which  will  be  readily  accomitlished  by 
inspection  and  touch. 

Treatment. — The  treatment  of  this  condition  is  most  unsatisfac- 
tory. I  have  met  with  six  cases  of  marked  character,  and  m  not 
one  was  relief  given  by  treatment.  Whether  they  subsequently 
recovered  I  cannot  say,  but  they  certainly  were  not  cured  ^^dlile 
under  my  observation.  In  one  case,  which  I  saw  with  Dr.  Met- 
calfe, the  sensitive  area  was  the  vestibule,  and  to  this  we  applied 


116  DISEASES    OF    THE    VULVA. 

nitric  acid  so  as  to  destroy  the  mucous  membrane  completely  and 
followed  this  up  by  local  sedatives,  but  to  no  purpose.  In  another, 
which  I  attended  with  Dr.  Sims,  he  removed  portions  of  the  labia 
minora  and  of  the  vulvar  mucous  membrane  without  success.  In 
another  case  I  dissected  off  all  the  sensitive  tissue,  which  was  quite 
(.■xtensive.  This  patient,  the  wife  of  a  clergyman,  left  me  well,  and 
was  greatly  rejoiced;  but,  in  six  months,  I  received  a  letter  from 
her  declaring  that  she  was  worse  than  before  the  operation.  The 
treatment  wliich  I  would  recommend  from  my  experience  is  this: 
to  send  the  })atient  away  from  home  where,  in  addition  to  enjoy- 
ing change  of  air,  scene,  and  surroundings,  she  would  live  absque 
marito ;  to  put  her  upon  the  use  of  general  tonics,  as  arsenic, 
strychnine,  quinine,  and  iron ;  and  after  having  cured  any  local 
exciting  disease,  like  vulvitis  or  urethral  vegetations  or  tumors,  to 
make  frequent  ablutions  with  warm  water  and  apj^ly  sedative  and 
calmative  substances  in  the  form  of  lotions  or  ointments.  As 
examples  of  these,  I  would  mention  opium  or  its  salts,  carbolic 
acid,  chloroform,  and  iodoform.  Sometimes  benefit  seems  to  result 
from  strong  solutions  of  alum,  tannin  and  similar  agents. 

My  observation  of  the  results  of  caustics  and  the  knife  is  not  such 
as  to  inspire  me  with  confidence  in  them. 

Irritable  Urethral  Caruncle. 

This  aifection  has,  likewise,  received  the  names  of  vascular 
tumor,  and  irritable  vascular  excrescence  of  the  urethra. 

Just  from  the  edges  of  the  meatus  urinarius,  and,  sometimes, 
along  its  walls  for  some  distance,  little  vascular  tumors  develop 
themselves,  which  render  this  canal  very  irritable,  and  in  this  way 
produce  a  great  deal  of  discomfort. 

Pa^/io%?/.— According  to  WedP  they  consist  of  hypertrophied 
papill'.e,  which,  as  they  enlarge,  are  accompanied  by  excessive 
growth  of  areolar  tissue.  They  are  extremely  vascular,  capillary 
vessels  of  considerable  size  being  found  witliin  them,  ramifying  in 
transverse  sections,  very  much  like  the  vasa  vorticosa  of  the  choroid. 
Dr.  Reid,2  of  Edinburgh,  declares  that  they  are  richly  supplied  wdth 
nervous  filaments.  These  two  anatomical  facts  account  for  two 
corresponding  clinical  observations,  that  they  bleed  very  freely  and 
readily,  and  that  ihaj  are  almost  as  sensitive  to  the  touch  as  a 
neuroma.    Savage  styles  these  curious  growths  "  pseudo-angiomata," 

'  Pathological  Anatomy.  2  Simpson,  Diseases  of  Women,  p.  276. 


IRRITABLE    URETHRAL    CARUNCLE.  117 

and  asserts  that  within  them,  cystic  cavities,  probably  the  remains 
of  urethral  glands,  are  occasionally  found,  tilled  with  mucus. 

Causes. — Of  the  etiology  of  this  aflection  nothing  is  known.  It 
develops  in  the  young  and  old  ;  the  married  and  single. 

Si/mptoms. — The  patient  complains  of  pain  upon  sexual  inter- 
course, in  passing  urine,  in  w^alking,  and  upon  the  slightest  contact 
of  the  clothing.  Sleep  is  disturbed  by  these  means,  and  by  the 
increase  of  sensitiveness  engendered  by  the  warmth  of  the  bed. 
As  a  consequence,  she  becomes  nervous,  hysterical,  and  greatly 
depressed  in  spirits.  Her  whole  thoughts  often  become  fixed  upon 
this  one  painfully  absorbing  topic,  and  a  most  wretched  mental  state 
is  at  times  produced.  Of  course,  these  grave  results  occur  only  in 
very  aggravated  cases ;  but,  even  in  minor  ones,  they  are  present 
in  slight  degree. 

Dr.  T.  F.  Cock  informed  me  of  a  case  in  which  a  patient  became 
so  much  depressed  from  this  cause  that  she  committed  suicide, 
and  I  have  a  similar  statement  of  another  case  from  a  non-profes- 
sional source.  In  the  latter,  the  time  had  been  a})pointed  for 
removal  of  the  growth  when  the  patient  destroyed  her  life.  I 
should  be  sorry  to  leave  the  impression,  that  mental  alienation  of 
grave  character  is  likely  to  develop  from  these  little  growths;  it  is 
not.  A  certain  degree  of  it  is  very  apt  to  be  met  with;  and,  in 
rare  cases,  where  the  suffering  is  very  great,  it  sometimes  becomes 
excessive.  To  convey  some  idea  of  the  amount" of  pain  induced  by 
urination  in  some  cases,  I  quote  the  following:  "I  was  told  by  a 
shepherd's  wife,  who  had  one  of  these  sensitive  caruncles  at  the 
orifice  of  the  urethra,  that  whenever  she  was  obliged  to  pass  water, 
she  was  in  the  habit  of  going  to  some  distance  away  from  her 
cottage,  in  order  that  she  might  moan  and  scream  unheard,  and 
not  distress  her  family  with  the  sound  of  her  cries,  so  intense  and 
intolerable  was  the  suffering  which  at  such  times  she  experienced."^ 

Physical  Signs. — The  patient  being  placed  upon  the  back  with 
the  thighs  flexed  and  the  knees  separated,  inspection  shows  at  the 
meatus  urinarius,  a  florid,  vascular  growth,  varying  in  size,  from 
that  of  a  cherry-stone  to  that  of  a  pullet's  egg.  Scanzoni  declares 
that  they  may  grow  to  the  size  of  a  goose's  egg.  Sometimes,  instead 
of  one,  quite  a  number  may  be  found,  of  small  size,  extending 
around  the  meatus  or  up  the  canal.  Where  the  canal  itself  is 
invaded,  the  cases  are  always  very  difficult  of  cure,  on  account  of 
the  difficulty  in  reaching  the  morbid  developments. 


'  Simpson,  op.  cit. 


118  DISEASES    OF    THE    VULVA. 

Differentiation. — There  are  but  two  conditions  witli  which  I  have 
ever  known  the  disease  confounded.  One  is  prolapsus  ure three  or 
aversion  of  the  mucous  membrane  of  the  canal ;  the  other  syphilitic 
growths  of  warty  character.  From  the  first  a  careful  examination 
will  readily  distinguish  it,  and  when  the  second  exists  similar 
developments  will  be  found  upon  other  parts  of  the  vulva.  Besides 
neither  of  these  conditions  is  nearly  so  annoying  and  painful  as  that 
which  we  are  considering. 

Course  and  Duration. — It  is  impossible  to  say  how  long  these 
growths  will  continue  to  exist  when  uninterfered  with.  I  have 
known  them  last  for  years  without  continuing  to  develop,  but 
retaining  a  small  size,  and  being  always  excessively  sensitive  and 
annoying. 

Prognosis. — In  case  a  single  large  caruncle  exist,  an  almost  posi- 
tive promise  of  relief  may  be  held  out  from  its  removal ;  but  where  a 
number  of  small,  fungous,  warty  growths  surround  the  meatus  and 
extend  up  the  urethra,  cure  is  extremely  difficult,  for  no  sooner  are 
they  removed,  than  the  morbid  process  of  development  rapidly  pro- 
duces more.  Another  discouraging  feature  of  these  cases  is  this,  a 
nervous  hypersesthesia  is  engendered  by  the  growth,  which  lasts  long 
after  its  removal.  It  behooves  the  operator  in  such  cases  always  to 
be  guarded  in  his  promises,  at  tlie  same  time  that  he  urges  interfer- 
ence as  the  only  hope  for  relief  in  the  present,  and  safety  from 
increased  trouble  in  the  future. 

Treatment. — Before  operating  the  patient  should  be  thoroughly 
anaesthetized  and  placed  upon  the  back,  with  the  thighs  flexed 
and  the  knees  widely  separated.  The  labia  being  then  separated 
by  an  assistant  on  each  side,  the  tumor  should  be  seized  near  its 
base  by  forceps,  pulled  towards  the  operator,  and  its  attachment 
cut  by  scissors.  Very  free  hemorrhage  may  occur.  To  control 
this,  the  raw  surface  should  be  wiped  dry  and  thoroughly  touched 
with  fuming  nitric  acid,  or  a  stick  of  nitrate  of  silver.  Should 
this  not  control  it,  the  edges  may  be  brought  together  by  suture. 

This  operation  may  be  very  nicely  performed  by  galvano-cautery, 
if  an  instrument  be  attainable.  By  this  means  not  only  is  hemor- 
rhage prevented,  the  base  is  also  thoroughly  cauterized,  which  is  a 
great  safeguard  against  return  of  the  growth. 

Where  the  urethra  has  been  invaded  it  should  be  thoroughly 
stretched  by  little  retractors  introduced  within  it,  and  held  by 
assistants,  and  the  growths  thus  exposed  be  cut  off  by  scissors,  or 
scraped  from  their  attachments  by  a  steel  curette.  After  removal, 
their  bases  should  be  very  cautiously  touched  with  nitric  acid^ 


PROLAFSL^S    UKETHH^.  119 

nitrate  of  silver,  or,  what  is  still  better  as  preventive  of  relapses, 
the  actual  cautery. 

Urethral  Venous  Angioma. 

This  is  a  disease  affecting  the  urethro-vaginal  tubercle  or  ante- 
rior half  of  the  urethro-vaginal  septum.  It  sometimes  attains  large 
size,  and  projects  between  the  labia.  From  irritable  caruncle  or 
vascular  excrescence  it  can  be  differentiated  by  its  want  of  sensi- 
tiveness. 

It  appears,  says  Savage,'  to  be  due  to  venous  congestion,  analogous 
to  that  giving  rise  to  priapism. 

Its  treatment  is  identical  with  that  of  urethral  caruncle. 

Prolapsus  Urethrae. 

This  accident,  which  has  likewise  been  described  as  procidentia 
and  eversio  urethroe,  consists  of  prolapse  of  the  urethral  mucous 
membrane,  with  proliferation  of  the  underlying  connective  tissue. 
It  is  not  commonly  met  with,  but  at  times  produces  considerable 
irritation  of  the  urethra  and  bladder,  and  leads  to  an  erroneous 
diagnosis  of  irritable  caruncle.  I  have  met  with  it  only  in  adults 
of  enfeebled  constitution  and  advanced  age ;  but  Guersant,  in  the 
Revue  de  Therapeutique^  declares  that  he  has  seen  fifteen  cases  in 
little  girls  between  two  and  twelve  years  of  age.  Diagnosis  is 
easy.  A  roseate  projection  encircles  the  meatus,  which  is  sensitive 
and  liable  to  bleed.  The  only  diseases  with  which  it  could  be  con- 
founded are,  irritable  caruncle,  urethral  polypus,  and  venous  angi- 
oma. From  all  these  it  can  readily  be  differentiated  by  careful 
examination,  which  shows  that  it  entirely  surrounds  the  meatus, 
while  they  do  so  only  in  part.  The  extreme  sensitiveness  of  irri- 
table caruncle  is  not  a  differential  sign  which  can  be  relied  upon, 
for  I  have  seen  prolapse  of  the  urethra  develop  this  S3'mptom  very 
decidedly. 

It  may  for  some  time  exist  without  symptoms,  but  usually  soon 
creates  difficult  and  painful  micturition,  pruritus  vulvae,  and  leu- 
corrhoeal  discharge. 

Treatment. — The  simplest  method  of  treatment  is  to  seize  the 
prolapsed  circle  with  tooth-forceps,  the  patient  being  anaesthetized, 
draw  it  down  with  very  little  force,  and  cut  it  off  with  curved 
scissors.  The  resulting  hemorrhage  will  readily  be  controlled  by 
applying  a  pledget  of  lint  or  cotton,  saturated  with  a  solution  of 
persulphate  of  iron,  one-third  of  the  full  strength,  against  the  raw 


'  Savage,  op.  cit. 


120  DISEASES    OF    THE    VULVA. 

surface,  and  making  pressure  by  the  finger  for  some  minutes. 
Should  it  be  deemed  necessary  to  continue  it  longer,  this  may  be 
done  by  a  T  bandage. 

If  great  vascularity  leads  to  fear  of  hemorrhage,  the  ingenious 
method  of  Sequin  may  be  adopted  with  advantage.  This  consists 
in  introducing  a  female  catheter  into  the  bladder,  and  ligating  the 
prolapsed  part  to  it  so  as  to  strangulate  it  entirely.  The  catheter 
is  left  in  situ  until  released  by  sloughing  ofl'  of  the  ligated  part. 

In  one  case  I  drew  down  the  prolapsed  tissue,  passed  a  double 
silk  ligature  through  its  base,  and  tied  the  two  halves.  The  cure 
was  perfect. 

A  better  operation  than  either  of  these  would  be  encircling  the 
prolapsed  tissue,  which  should  be  well  drawn  down,  by  the  galvano- 
caustic  wire,  removing  the  mass  in  this  way,  and  keeping  a  catheter 
in  the  bladder  for  some  days  if  necessary. 

Coccyodynia. 

Definition  and  Frequency. — This  aftection  consists  in  a  morbid 
state  of  the  coccyx,  or  the  muscles  attached  to  it,  which  renders 
their  contraction,  and  the  consequent  movement  of  the  bone,  very 
painful.  It  is  of  frequent  occurrence,  numerous  cases  having  been 
observed,  since  attention  has  been  called  to  it,  by  practitioners  who 
saw  it  previously  without  regarding  it  as  a  special  disorder. 

Hidory. — Coccyodynia  was  first  described,  in  1844,  by  the  late 
Dr.  !N^ott,  of  this  city.  Under  the  name  of  neuralgia  of  the  coccyx 
he  described  a  case  which  so  fully  embodies  the  symptoms  and 
treatment  of  the  aftection,  that  I  cannot  refrain  from  a  free  quota- 
tion of  it. 

"  Extirpation  of  the  Os  Coccygis  for  Neuralgia. — Miss ,  aged 

about  25,  had  been  very  much  deranged  in  general  health  and 
suftering  from  neuralgia  for  ten  months,  for  which  she  was  treated 
by  an  eminent  physician  in  Charleston,  and  afterwards  by  Prof. 
Jones  in  New  Orleans.  She  came  under  my  care  the  latter  part 
of  June,  1843,  at  which  time  her  condition  was  a  deplorable 
one;  her  general  health  was  completely  shattered  and  strength 
exhausted  ;  dyspepsia  ;  constant  nervous  headaches  ;  menstruation 
regular  though  difiicult ;  excruciating  pain  at  the  point  of  the 
coccyx  ;  pains  in  the  uterus,  vagina,  neck  of  the  bladder,  and  back. 
The  most  'prominent  symptom  was  the  excruciating  pain  at  the  point  of 
the  coccyx,  which  became  intolerable  when  she  sat  up,  walked,  or  went  to 
stool,  or  in  short  when  motion  or  pressure  was  communicated  to  it  in  any 
way.    This  symptom  was  so  peculiar,  that  I  was  led  to  suspect  some 


COCCYODYNIA.  121 

organic  lesion  about  the  coccyx ;  and  on  questioning  her  closely,  she 
informed  nie  that  she  had  fallen  ahout  four  years  ago  and  received 
a  blow  upon  the  coccyx,  which  gave  her  a  good  deal  of  pain  at  the 
time  and  for  several  weeks  afterwards ;  but  these  symptoms  passed 
off,  and  did  not  return  until  about  ten  months  before  I  saw  her. 
This  fact  had  been  concealed  from  her  former  medical  attendants. 

"  I  then  told  her  that  her  physicians  had  exhausted  all  the  arti- 
cles of  the  materia  medica  which  afforded  any  }»rospect  of  relief, 
and  that  she  had  better  consent  to  an  examination  to  ascertain 
whether  the  coccyx,  either  by  disease  or  displacement,  had  not 
become  a  source  of  irritation  to  one  or  more  of  the  nerves  in  its 
vicinity.  She  consented,  and  on  examining  the  whole  course  of  the 
spine,  I  found  no  tenderness  of  any  consequence  until  my  finger 
touched  the  point  of  the  coccyx,  when  she  screamed  with  pain, 
I  then  proposed  the  extirpation  of  this  bone  as  the  only  chance  of 
relief.  She  had  suffered  so  long  and  so  severely  that  she  did  not 
hesitate,  and  told  me  she  was  in  my  hands  to  do  what  I  thought 
best,  and  would  submit  to  anything  I  would  advise. 

"  Accordingly,  on  the  2d  of  July,  I  made  an  incision  down  to 
the  bone,  and  extending  from  the  point  upwards  two  inches;  I 
then  disarticulated  the  bone  at  the  second  joint,  divided  the  mus- 
cular and  ligamentous  attachments,  and  without  much  difficulty 
dissected  out  the  two  terminating  bones.  On  examining  the  bones 
after  the  operation,  I  found  the  left  one  carious  and  hollowed  out 
to  a  mere  shell ;  the  nerves  were  exquisitely  sensitive,  and  the 
operation,  though  short,  was  one  of  the  most  painful  I  ever  per- 
formed. For  several  hours  after,  the  pains  were  extremely  violent, 
coming  on  every  ten  or  fifteen  minutes,  and  accompanied  by  a  sen- 
sation of  bearing  down  like  labor-pains.  Morphine  in  large  doses 
and  other  anodynes  afforded  no  relief;  the  pains  became  gradually 
less  frequent  and  less  violent;  tlie  wound  soon  healed,  and  at  the 
end  of  a  month  the  local  disease  disappeared  and  the  general  health 
was  much  improved."^ 

Although,  as  will  be  here  seen,  Dr.  N'ott  gave  every  detail  with 
which  we  are  now  familiar,  as  to  the  symptomatology  and  treat- 
ment of  this  affection,  the  subject  was  nearly  forgotten  until  the 
year  1861,  when  it  was  again  described,  almost  simultaneously^  by 
Simpson,  of  Scotland,  who  gave  it  its  name,^  and  Scanzoni,  of  Ger- 

>  N.  O.  Med.  Journ.,  May,  1844. 

2  In  Prof.  Alexander  Simpson's  edition  of  Sir  James  Simpson's  post-humous 
volume  on  Diseases  of  Women,  the  name  coccygodynia  is  used.  In  his  Clinical  Lec- 
tures, published  in  Philadelphia,  1863,  the  name  which  I  here  employ  appears. 


122  DISEASES    OF    THE    VULVA. 

many.  ^Ve  have  in  this  another  instance,  of  which  so  many  exist, 
of  the  complete  oblivion  into  which  a  few  years  may  cast  a  valu- 
able contribution  to  science.  Surely  in  such  a  case  he  who  revives 
what  is  forgotten  deserves  as  much  credit  as  he  who  originally 
made  the  discovery. 

Anatomy. — The  coccyx  serves  as  a  point  of  attachment  for  the 
greater  and  lesser  sacro-sciatic  ligaments,  the  ischio-coccygei  mus- 
cles, the  sphincter  ani,  levatores  ani,  and  some  of  the  fibres  of 
the  glutei  muscles.  These  are  thrown  into  activity  by  certain 
movements,  as  rising  from  the  sitting  into  the  standing  posture, 
the  act  of  defecation,  etc.,  and  in  such  acts  the  existence  of  the 
disorder  which  we  are  considering  is  revealed. 

Patliology. — The  peculiar  pain  which  characterizes  this  disease 
has,  according  to  my  experience,  a  variety  of  causes ;  I  have  re- 
moved one  coccyx  in  which  a  fracture  with  dislocation,  received  in 
early  life,  Avliich  caused  it  to  jut  in  at  a  right  angle  to  the  sacrum, 
was  its  source;  another  in  which,  as  in  Dr.  Il^ott's  case,  just  re- 
corded, caries  existed ;  while  in  still  a  third  no  abnormal  condition 
could  be  discovered.  In  such  cases  as  the  last,  the  pain  which 
characterizes  it  is  probably  due  to  a  hyper-sensitive  state  of  the 
fibrous  tissues  surrounding  the  coccyx,  or  of  that  making  up  the 
tendinous  expansions  of  the  muscles.  This  may  at  times  be,  as 
Prof.  Simpson  has  suggested,  of  rheumatic  character ;  but  it  appears 
to  me  that  it  is  very  generally  a  neuralgic  state,  due  to  uterine  or 
ovarian  disease,  of  which  coccyodynia  is  a  frequent  consequence. 

As  a  rule,  so  long  as  the  bone  is  uninfluenced  by  contraction  of 
the  muscles  attached  to  it,  no  pain  is  experienced,  but  as  soon  as 
contraction  produces  motion  it  is  excited. 

Causes. — It  occurs  most  frequently  in  women  who  have  borne 
children,  but  it  is  by  no  means  confined  to  them.  I  have  on  two 
occasions  met  with  it  in  young,  unmarried  ladies,  and  Ilerschehnan 
reports  two  cases  in  children  from  four  to  five  years  of  as-e. 

T  T     •        ^ 

its  cliiet  causes  are  tlie  following : — 

Blows  or  falls  u[)on  the  coccyx. 

Injuries  inflicted  by  parturition. 

The  influence  of  cold  and  exposure. 

Uterine  and  ovarian  disease. 

Horseback  exercise.^  (?) 
In  a  case  mentioned   by  Courty  the   patient  had   the  peculiar 
habit  of  sleeping  with  the  buttocks   uncovered,  and  the  sacrum 

'  Scauzoni. 


COCCYODYNIA.  123 

pressed  against  the  wall.  In  nine  of  Scanzoni's  cases  the  condition 
followed  parturition ;  in  live,  the  use  of  the  obstetric  forceps ; 
and  in  two,  horseback  exercise  was  the  only  cause  ascertainable. 

Syiiiptoms. — The  patient,  upon  sitting  down,  rising,  making  any 
eifort,  or  passing  feces  through  the  rectum,  experiences  severe  pain 
over  the  coccyx.  In  some  cases  this  is  so  severe  as  to  cause  the 
greatest  dread  of  sudden  or  violent  movement.  In  others,  the 
patient  is  unable  to  sit  on  account  of  the  discomfort  caused  by  press- 
ure on  the  bone.  The  most  trying  process  is  that  of  rising  from 
a  low  seat,  and,  to  accomplish  this,  the  sufferer  will  obtain  all  the 
aid  that  is  practicable,  by  assistance  with  the  hands,  which  will  be 
placed  as  auxiliary  supports  upon  the  edges  of  the  chair  or  stool 
upon  which  she  rests. 

.Differentiation. — The  only  conditions  with  which  this  may  be 
confounded  are  painful  hemorrhoids,  fissure  of  the  anus,  and  a 
spasmodic  condition  about  the  muscles  of  this  part,  due  to  ascarides 
in  the  rectum.  From  these  a  careful  and  thorough  physical  exami- 
nation will  alwaj^s  readily  distinguish  it. 

Prognosis. — Coccyodynia  often  lasts  for  years,  annoying  and 
distressing  tlio  i)atient,  but  never  to  any  degree  depreciating  her 
health  or  constitutional  state.  If  left  to  nature,  it  may  wear  itself 
out,  but  it  is  probable  that  it  would  generally  remain  for  a  long 
time,  if  not  relieved  by  art. 

Treatment. — Should  this  disorder  arise,  as  it  so  often  does,  from 
uterine  disease,  that  should  be  removed  by  treatment  before  any 
hope  is  indulged  in  tliat  it  will  disappear.  In  slight  cases,  blister- 
ing and  the  endermic  use  of  morphia  may  effect  a  cure.  Should 
they  not  do  so  recourse  should  be  had  to  one  of  two  radical 
methods  of  cure,  section  of  the  diseased  muscles,  or  amputation  of 
the  bone  to  which  they  are  attached.  The  first,  placed  at  our  dis- 
posal by  the  late  Prof.  Simpson,  consists  in  severing  the  attach- 
ments of  all  the  coccygeal  muscles ;  the  second  in  extirpating  the 
coccyx  itself,  after  the  plan  of  Dr.  I^ott. 

The  first  operation  may  be  performed  subcutaneously  by  an  ordi- 
nary tenotomy  knife.  This  is  passed  under  the  skin  at  the  lowest 
point  of  the  coccyx,  turned  flat,  and  carried  up  between  the  skin 
and  cellular  tissue  until  its  point  reaches  the  sacro-coccygeal  junction. 
Then  it  is  turned  so  that  in  withdrawing  it  an  incision  may  be 
made  which  entirely  frees  the  coccyx  from  muscular  attachments. 
The  knife  is  then  introduced  on  the  other  side  so  as  to  repeat  the 
section  there.  As  is  usually  the  case  in  subcutaneous  operations, 
no  hemorrhage  occurs  unless  some  large  vessel  be  injured.     I  have 


124  DISEASES    OF    THE    VULVA. 

resorted  to  this  procedure  but  once,  when  I  found  it  exceedingly 
difficult  of  accomplishment,  and  it  proved  an  entire  failure  in 
giving  relief. 

In  fat  women  subcutaneous  section  of  the  muscles  attached  to 
the  coccyx  is  by  no  means  so  easy  a  matter  as  one  would  suppose 
who  has  not  made  the  experiment.  Under  these  circumstances 
the  operation  is  simplified  and  rendered  more  certain  by  making 
an  incision  down  upon  the  coccyx,  lifting  the  exposed  extremity 
of  this  bone  with  the  finger,  and  then  with  a  pair  of  scissors  sever- 
ing the  muscles.  This  procedure  is  both  easy  of  performance  and 
certain  as  to  result ;  that  is,  supposing  that  it  is  resorted  to  in  a 
case  really  demanding  it. 

Should  detachment  of  the  muscles  fail,  as  it  will  do  if  the  bone 
be  diseased,  an  incision  should  be  made  over  the  coccyx,  the  bone 
laid  bare  by  severance  of  its  attachments,  and  the  whole  of  it 
removed  by  a  pair  of  bone  forceps,  or  disarticulated  by  the  knife  as 
practised  by  Dr.  ISTott  in  the  case  already  detailed.  By  one  of  these 
procedures  cure  can  be  confidently  promised,  and  as  neither  is 
attended  by  danger,  our  resources  in  this  afl:ection  may  be  regarded 
with  great  satisfaction. 

Many  slight  cases  of  coccyodynia  occur,  however,  which  pass 
away  with  time  and  palliative  treatment.  The  gynecologist  should 
take  care  that  operation  is  not  resorted  to  too  early. 

We  have  now  considered  the  most  frequent  and  important  of  the 
diseases  of  the  vulva.  There  are  others  which  have  not  been  men- 
tioned and  which  do  not  require  special  attention,  as  they  possess 
the  same  characteristics  as  similar  morbid  states  developing  in 
other  parts  of  the  body. 

Tumors  of  considerable  size  may  spring  from  the  external  organs 
of  generation.  Thus  we  may  have  tumors  resulting  from  hyper- 
trophy of  the  clitoris,  or  of  the  nymphpe,  lipoma  of  the  labia  majora, 
and  cystic  tumors  of  large  size  growing  l)y  a  pedicle  from  the  same 
site.  Malignant  disease  also  frequently  attacks  these  organs,  where 
it  runs  its  usual  course ;  differing  in  nothing  from  its  career  in 
other  locations. 


RUPTURE    OF    THE    PERINEUM.  125 


CHAPTER    V. 


RUPTURE  OF  THE  PERINEUM. 


Anatomy. — A  great  deal  of  the  difficulty,  which  has  attended 
the  repair  of  ruptured  perineum,  depends  upon  an  incorrect  under- 
standing of  the  anatomy  of  the  part  which  is  to  be  subjected  to 
operation.  An  imperfect  idea  is  conveyed  by  the  deiinition  of  the 
perineum,  as  a  part  consisting  of  the  union  of  the  tendons  of  a 
number  of  muscles  eft'ected  at  a  point  situated  between  the  four- 
chette  and  anus.  Should  the  superficial  surface,  thus  indicated,  be 
united  by  reparative  operation,  little  good  would  result,  for  the 
sustaining  powers  of  the  perineum  exist  not  in  this,  but  in  the 
thick  and  firm  triangle,  called  the  perineal  body,  of  which  this 
muscular  plane  is  the  base,  and  the  apex  of  which  extends  up  to  the 
point  of  divergence  of  the  posterior  vaginal  and  anterior  rectal  walls. 

Proceeding  in  close  proximity  with  each  other  towards  the  jjelvic 
outlet,  the  vagina  and  rectum  diverge  at  a  point  above  the  perineum ; 
the  one  arching  forwards  in  coincidence  with  the  pelvic  curve,  the 
other  slightly  backwards  towards  the  coccyx.  In  this  way  an 
irregular  triangle  is  created,  of  which  the  base  is  the  perineum, 
one  side  the  posterior  vaginal  wall,  and  the  otlier  the  anterior 
wall  of  the  rectum.  This  body,  having  the  union  of  muscular 
tendons  as  its  base,  is  itself  composed  of  fibro-elastic  tissue  and 
bloodvessels.  One  of  its  sides  resting  upon  the  rectum,  the  other 
gives  strength,  elasticity,  and  firmness  directly  to  the  posterior 
wall  of  the  vagina;  while  this  wall,  being  by  it  pressed  against  the 
anterior  or  upper  vaginal  wall,  sustains  it  and  the  bladder  which 
lies  upon  it.  Figs  22  and  23  will  show  by  schematic  diagram  the 
relations  of  the  perineal  body  and  the  effect  of  its  removal  upon 
the  vaginal  walls.  The  anterior  or  upper  wall,  after  its  removal 
by  rupture,  lacks  support  and  falls  downwards,  prolapse  of  this 
wall  occurring,  with  cystocele.  The  normal  direction  of  the  poste- 
rior wall  is  destroyed.  Instead  of  its  archino;  forwards  towards  the 
vulva,  it  runs  in  a  straight  line  to  the  anus.  The  result  of 
this  change  of  direction,  with  the  coincident  loss  of  support  from 
the  strong,  elastic  perineal  body,  is  to  create  a  sagging  forwards, 


12Q  RUPTURE  OF  THE  PERINEUM. 

and  soon  prolapse  of  this  wall  follows  that  of  the  anterior,  and 
uterine  displacement  is  a  consequence. 

Fiff.  22.  Fig.  23. 


Perineal  body  perfect ;  both  vaginal         Perineal  budy  removed  by  ruptnre  ;  both 
walls  sustained.  vaginal  walls  robbed  of  support. 

When  a  woman  with  an  uninjured  perineum  is  placed  upon  the 
back,  and  the  finger  of  the  examiner  is  passed  into  the  vagina,  a.8 

it  passes  over  the  perineal  body  it  will 
Fig-  24.  })Q  firmly  pressed  against  the  upper 

vaginal  wall.  Upon  the  withdrawal 
of  the  finger,  the  separated  walls  will 
be  observed  to  come  in  contact  at 
once  by  the  rising  of  the  posterior  wall. 
If  the  perineal  body  have  lost  its 
power,  no  such  upward  pressure  is 
found  to  exist,  and  the  vaginal  walls 
are  discovered  to  be  in  less  close  con- 
tact. 

After  operation  for  closure  of  the 
ruptured  perineum,  an  examination  of 
this  kind  should  be  made.  If  the  up- 
ward pressure  of  the  perineal  body  is 

Perineum   improperly  repaired,      fo^nd    to    be    Ruflicient    tO    bring    the 
Perineal  body  not  restored  to  place.  .        .  •  i      i  • 

Vaginal  walls  not  sustained.  posterior  in  contact  With  the  anterior 

vaginal  wall,  the  object  of  the  opera- 
tion has  been  attained.  If  it  do  not  so,  both  walls  will  lack  sup- 
port, in  spite  of  the  fact  that  the  superficial  perineum,  the  base  of 


RUPTURE    OF    THE    PERINEUM.  127 

the  perineal  triangle,  has  been  united  and  appears  perfect.     Tlie 
latter  result  will  deceive  the  patient,  and  may  deceive  the  surgeon, 
with  false  hopes.      The  former  will  alone  give  future  immunity 
from  the  dangers  of  vaginal  prolapse  and  its  consequences. 
Vaiieties. — All  cases  may  be  classed  under  tw^o  heads: 
Complete  and  Partial  Rupture. 

These  include  the  following  degrees  of  destruction: 

1st.  Superficial  rupture  of  the  fourchette  and  perineum,  not 
involving  the  sphincters; 

2d.  Rupture  to  the  sphincter  ani; 

3d.  Rupture  through  the  sphincter  ani ; 

4th.  Rupture  through  the  sphincter  ani  and  involving  the  recto- 
vaginal septum. 

Complete  rupture  presents  such  serious  discomforts  as  a  conse- 
quence, that  partial  rupture  is  by  many  viewed  as  a  trivial  circum- 
stance. So  it  is  by  comparison,  but  so  likely  is  it  to  be  followed 
by  prolapse  of  one  or  both  vaginal  walls  that  it  should  never  be 
undervalued.  So  soon  as  such  prolapse  occurs,  uterine,  vesical,  and 
rectal  troubles  become  almost  inevitable. 

The  evils  resulting  from  partial  rupture  are  by  no  means  insig- 
nificant, but  they  are  more  remote  and  more  tolerable  than  those 
which  follow  complete.  When  the  sphincter  ani  is  torn  throu2-h, 
and  still  more  markedly  when  the  rectal,  wall  is  ruptured,  incon- 
tinence of  feces  and  rectal  gases  occurs  to  such  an  extent  as  to 
embitter  the  life  of  the  unfortunate  patient.  The  consequences  of 
rupture  of  the  perineum  may  thus  be  presented : 

Subinvolution  of  the  vagina ; 

Prolapsus  vaginae  with  cystocele  or  rectocele ; 

Prolapsus  uteri ; 

Incontinence  of  feces  and  intestinal  gases  ; 

Prolapsus  recti. 

The  first  three  of  these  may  result  from  both  varieties  of  rupture, 
complete  and  incomplete.  The  last  two  attend  only  the  former. 
Even  when  the  two  passages  are  laid  into  one,' it  is  sometimes 
surprising  to  see  how  little  the  patient  may  suffer  ;  but  generally, 
under  these  circumstances,  her  condition  is  truly  deplorable. 
Fecal  matters  and  gases  pass  without  control,  and  the  uterus, 
vagina,  bladder,  and  rectum,  tend  so  strongly  to  descend,  that, 
exercise,  muscular  efforts,  or  tenesmus,  produce  weariness,  pelvic 
pain,  and  traction  upon  the  broad  ligaments.  In  some  instances, 
so  great  is  the  disturbance  of  function,  that  the  unfortunate  woman 


128  RUPTURE    OF    THE    PERINEUM. 

finds  herself  an  object  of  disgust  to  her  associates  and  even  of 
loathing  to  her  husband. 

Subinvolution  of  the  vagina  I  have  never  seen  alluded  to  as  a 
consequence  of  rupture  of  the  perineum ;  but  I  see  the  two  con- 
ditions too  often  coexistent  to  regard  it  as  a  mere  coincidence. 
''The  muscular  walls  of  the  vagina,"  says  Savage,  "are  not  separable 
into  coats  or  layers.  Two-thirds  of  the  thickness  of  tlie  vagina, 
varying  from  2-3  lines  above  to  5-6  below,  is  made  up  of  this  mus- 
cular portion;  the  inner  third  consists  of  a  dense,  cellular  lining- 
membrane,  inseparably  united  to  it."  The  elastic,  contractile 
elements  of  this  canal  are  identical  in  structure  with  uterine  fibre ; 
and  development  occurs  in  them  as  in  those  of  the  uterus  under 
the  stimulus  of  gestation.  A  retrograde  metamorphosis  likewise 
affects  them  subsequent  to  labor.  As  this  process  is  often  inter- 
fered with  in  the  uterus  by  ru[>ture  of  the  cervix,  so  is  it  in  the 
vagina  by  rupture  of  the  perineum.  Let  any  one  appeal  to  his 
own  experience  for  the  frequency  of  subinvolution  of  the  vagina  as 
a  concomitant  of  rupture  of  the  perineum.  It  may  be  objected 
that  the  latter  often  results  from  difticult  and  particularly  from 
instrumental  delivery,  which  may  produce  both  conditions.  An 
examination  into  the  histories  of  cases  will  refute  this;  the  result  is 
often  produced  when  the  labor  has  been  very  rapid  and  unaided.  It 
may  again  be  suggested  that  prolapse  of  the  vagina,  a  consequence 
of  the  rupture,  excites  excessive  growth  in  its  walls ;  but  the  two 
things  coexist  where  perineal  rupture  has  not  resulted  in  vaginal 
prolapse,  almost  as  often  as  where  it  has  done  so. 

Causes. — The  usual  causes  of  rupture  of  the  perineum  are, 

Parturition ; 

Passage  of  a  large  tumor ; 

Use  of  forceps  ; 

Manual  deliver}'  ; 

Craniotomy  ; 

Injury  by  falls  or  blows. 

Minute  details  upon  this  subject  and  upon  means  which  should 
be  adopted  for  prevention,  will  be  found  in  works  upon  obstetrics. 
All  that  it  is  necessary  to  state  here  is  that  parturition  is  the  great 
exciting  cause  of  the  accident,  and  that  it  is  almost  never  met  with 
in  nulliparous  women,  except  after  removal  of  large  tumors  per 
vaginam. 

Prognosis.— In  an  incomplete  case  of  slight  character,  in  which 
neither  the  sphincter  vaginae  nor  sphincter  ani  has  been  injured, 


TREATMENT    AT    TIME    OF    OCCDBRENCE.  129 

no  evil  will  probably  result.  Although  the  wound,  occurring  as 
A  usually  does  immediately  after  labor,  is  extremely  unlikely  to 
neal  by  first  intention,  it  may  do  so  by  the  process  of  granulation 
without  interference  other  than  binding  the  thighs  together,  and 
producing  constipation  by  opium. 

The  first  and  second  degrees  of  the  accident  are  very  generally 
trifling  in  their  consequences,  and  frequently  pass  unnoticed  by 
both  patient  and  attendant.  The  third  is  an  evil  of  much  greater 
moment,  and  not  at  all  likely  to  undergo  spontaneous  cure  ;  while 
the  fourth  represents  the  most  serious  form  of  the  condition. 

The  greater  the  injury  the  less  likely  will  be  spontaneous  re- 
covery, and  the  more  probable  the  comi>lications  and  results  which 
have  been  mentioned.  It  may  be  affirmed  in  a  general  way,  that 
any  laceration  which  does  not  entirely  sever  the  sphincter  ani  may 
heal  without  surgical  treatment,  and  that  none  which  converts  the 
two  passages  into  one  will  do  so.  Even  when  the  rupture  has  been 
complete  it  has  been  asserted  that  spontaneous  cure  has  taken  place, 
but  such  reports  need  confirmation.  Peu'  once  afiirmed  that  he 
had  seen  a  woman  thus  injured,  and  who  passed  her  feces  involun- 
tarily, entirely  recover.  De  la  Motte  declares  that  thirty  years 
afterwards  he  met  and  examined  T^eu's  patient  in  Xormandy,  and 
found  that  no  recovery  had  occurred. 

Treatment  at  Thiie  of  Occurrence.— If  the  rupture  be  an  incomplete 
one,  in  which  it  is  not  deemed  advisable  to  resort  at  once  to 
suture,  an  eftbrt  should  always  be  made  to  secure  union  of  the 
lips  of  the  wound  by  the  following  means.  The  wound  being 
thoroughly  cleansed  of  blood-clots,  which  would  prevent  union, 
the  thighs  should  be  l)rought  together  and  kept  in  contact  by  a 
bandage  placed  around  tliem  at  the  knees.  The  patient  should 
then  be  placed  upon  the  side  so  as  to  cause  the  lochial  dii^oharge 
to  flow  through  tlie  superior  vaginal  commissure,  and  prevent  its 
pouring  over  the  raw  surface.  Opium  should  be  given  to  produce 
constipation,  the  bladder  be  kept  empty  by  use  of  the  catheter,  and, 
once  or  twice  in  every  twenty-four  hours,  the  patient  should  turn 
upon  the  back,  in  order  tliat  the  vagina  may  be  cautiously  and 
gently  syringed  out  with  tepid  water. 

This  plan  should  be  pursued  for  ten  or  twelve  days,  in  the  hope 
that  union  may  occur,  though,  unfortunately,  in  the  great  majority 
of  instances,  it  will  not  be  rewarded  by  success. 

Time  for  Operation. — Upon  this  point  authorities  differ  widely; 

'  Yelpeau,  Traite  de  I'Art  des  Accouchements,  vol.  ii,  p.  639. 

9 


130  RUPTURE    OF    THE    PERINEUM. 

some  urging  immediate  action,  some  advising  delay  until  the  effects 
of  parturition  have  entirely  passed  away,  while  others  compromise 
the  matter  by  giving  preference  to  the  plan  of  waiting  a  few^  days 
only.  To  the  lirst  class  belong  Baker  Brown,  Demarquay,  Scanzoni, 
Simon,  and  others  of  equal  weight.  Scanzoni  thus  clearly  points 
out  the  advantage  of  early  interference:  ''The  operation  should  be 
performed  just  after  the  delivery,  because  it  is  more  likely  that  the 
bleeding  lips  of  the  w^ound  will  then  unite,  and  because,  vivifica- 
tion  of  the  edges  not  being  necessary,  the  procedure  is  simpler  and 
less  dangerous."  The  worst  cases  of  the  accident  with  which  we 
meet  generally  follow  instrumental  or  manual  delivery,  and  when 
the  discovery  of  its  occurrence  is  made  the  patient  will  usually  be 
in  a  profound  anaesthetic  sleep.  Every  operator  should  be  prepared, 
under  such  circumstances,  to  attempt  re])air  of  the  injury,  for,  if 
he  succeed,  the  patient  will  be  saved  much  suffering,  while  failure 
will  not  in  any  w'ise  depreciate  her  condition.  For  this  reason  no 
case  of  obstetrical  instruments  should  be  considered  complete  which 
has  not  in  it  needles  and  sutures  for  performance  of  this  operation. 
I  have  in  a  number  of  instances  resorted  to  immediate  operation, 
and  the  result  of  my  experience  loads  me  always  to  adopt  it,  unless 
the  sphincter  ani  and  recto-vaginal  wall  be  implicated  in  the  lacera- 
tion to  such  an  extent  as  to  make  the  operation  a  serious  and  lengthy 
one,  or  to  insure  the  passage  of  lochial  discharge  between  the  lips 
of  the  wound.  Among  tliose  who  are  opposed  to  immediate  inter- 
ference are  Roux  and  Velpeau ;  while  !N"^laton,  Verneuil,  and 
Maisonneuve  advise  delay  for  a  few  da_ys,  wlien  all  hemorrhage 
will  have  ceased  and  the  edges  of  the  wound  be  covered  by  granu- 
lations.^ There  are  three  circumstances  which  tend  to  defeat  the 
success  of  immediate  operation.  First,  it  is  often  performed  by  one 
not  habituated  to  its  performance ;  and  being  practised  upon  a 
woman  who  having  just  been  delivered,  is  exposed  to  the  danger 
of  post-partum  hemorrhage,  and  surrounded  by  anxious  friends,  it 
is  likely  to  be  finished  too  hastily.  Second,  the  lochial  discharge, 
constantly  passing  over  the  lips  of  the  wound,  is  very  likely  to 
enter  and  prevent  union.  Third,  the  patient  being  confined  to  bed 
for  reasons  connected  with  parturition,  the  urine  is  passed  upon  the 
bedpan,  and  dribbling  over  the  wound  may  enter  with,  the  lochia 
and  prevent  adhesion. 

My  advice  and  practice  with  regard  to  this  point  are  decidedly 
tc-  give  the  patient  the  benefit  of  the  doubt  and  to  close  the  rupture 

-  Wieland  and  Dubrisay,  French  Trans,  of  Churchill  on  Dis.  of  Women. 


PERINEORRAPHY.  131 

at  once.  If  failure  follow,  however,  never,  unless  there  be  some 
special  reason  for  so  doing,  attempt  another  operation  before  the 
results  of  parturition  have  entirely  passed  away.  This  will  not  be 
before  the  lapse  of  two  or  three  months  from  the  time  of  delivery ; 
just  after  delivery  there  is  a  reason  for  operating  which  has  passed 
away  in  a  fortnight. 

Treatmejit  of  Cases  which  have  Cicati^ized. — The  operation  which 
is  now  generally  adopted  in  these  cases,  and  which  has  received 
the  name  of  periueorraphy,  consists  in  vivification  of  the  edges 
of  the  lips  t)f  the  wound  and  their  approximation  by  sutures. 
Although  the  accident  for  which  this  procedure  is  instituted  was 
described  by  the  ancients,  no  surgical  means  of  cure  were  ever 
advised  for  it  until  the  time  of  Ambrose  Pard  He  advised  the 
suture,  and  was  followed  in  its  use  by  his  pupil  Guillemeau. 
Subsequently  it  was  employed  by  Delamotte,  Saucerotte,  Trainel. 
Xoel,  and  others.  Dieftenbach  employed  it  successfully,  adding 
to  the  operation  oblique  lateral  incisions  involving  the  skin  and 
areolar  tissue,  for  the  purpose  of  relieving  tension  upon  the  parts 
brought  together  by  suture. 

About  the  3^ear  1832,  E,oux,  of  Paris,  obtained  the  most  bril- 
liant results  from  the  operation,  and  probably  its  elevation  to  the 
position  of  a  reliable  surgical  procedure  was  due  more  to  his 
achievements  than  to  those  of  any  other  individual.  He  employed 
the  quilled  suture,  and  cured  by  it  four  out  of  the  first  five  cases 
operated  upon.  Although  such  success  was  obtained  in  France 
at  this  period,  we  find  English  writers,  as  late  as  1852  and  1853,^ 
doubting  the  efiicacy  of  sutures,  and  advising  that  assistance 
should  be  limited  to  aiding  the  efforts  of  nature.  Of  late  ^^ears 
great  advances  have  been  made  in  the  operation  by  Mr.  Brown  in 
England;  Verneuil,  Laugier,  Demarquay,  and  others  in  France; 
Langenbeck  and  Simon  in  Germany ;  and  Sims,  Emmet,  Pozeman, 
Agnew,  and  Thompson  in  the  United  States. 

The  varieties  of  the  operation  now  before  the  profession  are  too 
numerous  to  require  mention.  Operators  dififer  chiefly  in  these 
respects ;  some  cut  the  tissues  alongside  the  perineum  or  the  sphincter 
ani  itself,  and  employ  the  quilled  suture,  while  others  make 
no  "  liberating  incisions,"  as  the  French  surgeons  style  them,  and 
employ  the  interrupted  suture.  The  varieties  of  quilled  suture 
operation  are  modifications  of  the  procedure  of  Roux;  those  of 
interrupted  silver  suture  of  Marion  Sims's  plan.     In  description  I 

'  Baker  Brown,  Surgical  Diseases  of  Women. 


132  RUPTURE  OF  THE  PEKINEUM!. 

shall  adlicre  to  no  one  particular  and  exact  method,  but  describe 
those  which  I  have  selected  as  best  in  my  own  practice,  and  after- 
wards allude  to  certain  special  modifications  advised  by  dijfterent 
operators. 

Preparation  of  the  Patient. — The  general  health  should  be  care- 
fully investigated.  If  it  be  bad,  the  operation  sliould  be  delayed, 
and  the  patient  put  upon  tonics  and  placed  under  the  best  hygienic 
circumstances.  For  a  Avoek  before  operation,  the  bowels  should  be 
kept  lax  by  some  mild  cathartic,  in  order  that  after  that  time  cure 
will  not  be  jeopardized  by  the  coming  dowai  of  scybalfe,  which 
have  not  been  removed  by  a  cathartic  given  twenty-four  hours 
before  operation.  This  point  is  one  of  a  great  deal  of  moment, 
and  should  not  be  overlooked.  The  following  prescriptions  I  would 
recommend  for  this  ]3urpose,  not  only  here,  but  before  other  ope- 
rations which  should  be  followed  by  constipation: 

R. — Seniiae  fol.  sj. 

Anisi  sem  cont.  5J. 
Aquae  bullientis,  Oj. 
M.  ft.  infiis.  cole,  et  adde 
Potassie  bitart.  5J. 
S.  A  claretglassful  to  be  taken  every  morning  upon  rising. 

R. — Sulpliuris  lactis,  ,5J. 
Putassae  bitart.  3J. 
Sennse  confect.  §j 
Mellis  aut  syrupi,  q.  s. 
M.  et  ft.  confect. 
S.  A  portion  equal  in  size  to  a  pigeon's  egg  every  morning  upon  rising,  and 
every  evening  upon  retiring. 

During  the  week  the  vagina  should  every  night  and  morning  be 
thoroughly  syringed  out  to  remove  secretions  and  quiet  local  irri- 
tation. The  patient,  dressed  for  bed,  should  be  jilaced  upon  a  table 
before  a  window  admitting  a  strong  light,  in  the  position  for 
lithotomy,  and  put  under  the  influence  of  an  ans^sthetic.  Four 
assistants  will  be  serviceable,  although  three  would  answer  the 
purpose.  One  of  these  should  administer  the  anfesthetic,  one 
should  hold  each  knee,  and  a  fourth  should  attend  to  the  duty  of 
handing  the  required  instruments  to  the  operator,  and  washing  the 
sponges  as  they  become  bloody.  The  assistants,  lifting  the  feet 
from  the  table  and  flexing  the  thighs  so  that  the  edges  of  the  tibiae 
will  be  horizontal,  should  hold  the  knees  clasped  under  the  arms 
and  steady  the  feet  with  the  hands  of  the  same  side,  while  the  un- 
occupied liands  of  the  other  side  retract  the  labia  and  expose  the 
ruptured  part. 


INSTRUMENTS    AND    APrHANCES    NEEDED. 


133 


The  assistant  holding  the  left  thigh  should  do  even  more  tlian 
this.  The  directions  just  given  should  be  observed  by  the  assistant 
holding  the  right  knee ;  he  who  holds  the  left  should  do  so  with 
the  right  arm,  clasping  it  with  this  and  retracting  the  labium  with 
the  right  hand,  while  with  the  left  he  sponges  the  wound  with 
sponges  held  in  long  wire  handles,  which  do  not  cause  his  hand  to 
obstruct  the  operator's  view.  It  will  at  first  appear  that  it  will  be 
difficult  for  one  assistant  to  do  all  this.  Let  him  who  thinks  so  try 
it,  and  he  will  find  that  it  is  not  so,  and  that  such  arrangement  of 
his  aids  will  be  greatly  to  his  advantage. 

Instruments  and  Appliances  Needed. — These  will  consist  of  long 
handled  curved  scissors ;  a  bistoury  with  narrow  blade ;  tooth  for- 
ceps and  tenaculum ;  one  dozen  small  sponges,  (size  of  a  walnut,) 
fixed  in  handles  ten  inches  long ;  artery  forceps ;  silk  ligatures ; 
round,  curved  needles  one  inch   and  a  half  long,  threaded  with 

Fig.  25. 


S.JIEMANN  -  CO-NV 

Tboinas's  tooth  forceps. 
Fig.  26. 


Slightly  curved  scissors. 
Fig.  27. 


Emmet's  scissors  sharply  curved. 

silk,  which  is  double  and  tied  at  the  eye  of  the  needle  b}^  as  small 
a  knot  as  possible ;  and,  if  the  quilled  suture  is  to  be  used,  pieces 
of  gum-elastic  catheter  to  be  employed  as  such.  A  basin  of  water 
should  be  in  readiness  to  receive  the  bloody  sponges,  and  a  pitcher, 
bucket,  or  other  reservoir  at  hand  to  supply  more  when  this  should 
be  changed. 

Operation  for  Partial  Rupture. — It  is  a  matter  of  great  surprise 
to  me  that  no  distinct  separation  should  be  made  by  writers 
between  the  descriptions  of  operations  for  partial  and  complete 


134 


RUFTUBE    OF    THE    PERINEUM. 


rupture.  The  first  is  a  procedure  in  which  the  merest  tyro  should 
succeed ;  it  scarcely  deserves  the  name  of  perineorraphy,  so  easy  and 
simple  is  it.  The  second  is  one  of  the  most  delicate  and  uncertain 
operations  in  gynecology,  and  even  the  most  skilful  may  fail  in  it. 
I  feel  sure  tliat  evil  has  arisen  from  their  confounding  a  simple  and 
difficult  procedure,  and  shall  make  a  wide  difl:erence  between  them. 
The  operation  for  partial  rupture  has  for  its  sole  object  the  resti- 
tution of  the  perineal  body.  That  for  complete  rupture  has  for  its 
main  object  the  restoration  of  the  power  and  functions  of  the 
sphincter  ani.  After  the  main  object  of  the  second  operation  has 
been  attained,  that  of  the  first  should  claim  attention ;  but  it  is, 
although  of  great  importance,  insignificant  in  comparison  with 
the  object  of  the  operation  for  complete  rupture. 

Before  describing  these  operations,  I  would  say  a  few  words  upon 
division  of  the  sphincter  ani.  I  have  operated  a  great  many  times 
for  rupture  of  the  perineum,  and  cannot  recall  a  case  of  final  failure ; 
thus  far  I  have  never  cut  the  sphincter.  My  experience,  as  does 
that  of  my  colleagues  in  the  Woman's  Hospital,  Sims,  Emmet,  and 
Peaslee,  leads  me  to  indorse  Dr.  Savage's  statement,  that  "the  success 
of  operations  for  the  closure  of  perineal  lacerations  is  obviously  not 
promoted  by  the  division  of  the  superficial  anal  sphincter." 

Let  the  operator  keep  clearly  in  mind  the  shape  and  dimensions 
of  the  body  which  he  is  about  to  restore.  It  is  a  triangle  with 
apex  above  and  base  below.      Two  surfaces  of  this  shape  are  to 

be  vivified  and  held  face  to  face  by 
sutures.  That  is  the  whole  operation. 
1st  part  of  (he  Operation. — All  being 
now  in  readiness,  the  assistant's  fin- 
gers are  fixed  upon  the  labia  by  tlie 
operator,  and  the  degree  of  traction 
they  are  to  practise  regulated. 
Seizing  the  mucous  membrane  just 
above  the  upper  border  of  the  anus, 
at  the  point  where  it  joins  the  skin, 
with  the  tooth-forceps  or  tenaculum, 
he  now  cuts  a  furrow  directly  up  the 
vagina,  extending  for  about  an  inch 
and  a  half.  While  this  is  being  done  the  anterior  vaginal  wall  may 
be  lifted,  and  the  posterior  wall  exposed,  by  the  introduction  of 


Fig.  28.' 


Profile  view  of  perineum.  A 
C,  rectal  wall.  A  B,  cutaneous 
surface.     B  C,  vaginal  wall. 


'  T  am  indebted  for  this  diagram  to  an  excellent  article  upon  perineorraphy  by  Dr. 
Theophilus  Parvin,  appearing  in  the  American  Practitioner. 


OPERATION     FOR    I'ARTIAL     RUPTURE. 


135 


Sims's  speculum  under  the  symphysis  pubis.  The  furrow  thus  cut 
marks  the  extent  of  the  base  of  the  perineal  body  and  the  point  of 
junction  of  the  bases  of  the  two  triangular  vivifications  now  to  be 
made,  one  on  the  right  and  the  other  on  the  left.  Now  seizing 
the  mucous  membrane  on  one  labium,  a  little  below  the  level  of 
the  meatus  urinarius,  two  other  furrows  are  cut  from  this  point, 
one  extending  to  the  upper,  the  other  to  the  lower  extremity  of 
the  first  or  basic  furrow.  A  little  undenuded  triangle  which  will 
be  left  in  the  midst  of  this  one  should  now  be  vivified.  The  same 
thing  is  done  on  the  opposite  side,  and  then  this  part  of  the  opera- 
tion is  complete. 

The  operator  now  stops  and  carefully  examines  to  see  if  any 
arteries  are  spouting,  and  if  any  undenuded  surfaces  still  remain. 
If  he  find  the  former  he  twists  them,  and,  if  necessary,  ties  them 
with  very  delicate  silk  ligatures,  which  he  cuts  short ;  if  the  latter 
he  catches  them  with  the  tenaculum,  and  with  the  bistoury  cuts 
them  away. 

The  first  step  of  the  operation  is  now  finished.  The  opera- 
tor should  not  hasten  to  the  second,  for  the  tissues  should  be  ex- 
posed  for  a  while  that   he  may 

be   assured    against   hemorrhage.  Fig.  29. 

Sutures  should  never  be  applied 
until  all  hemorrhage  has  been 
checked.  The  wound  made  is 
shown  in  Fig.  29. 

2(1  part  of  the  Operation. — Now 
taking  in  the  needle-holder  a 
round,  curved  needle,  about  two 
and  five-eighths  inches  long,  which 
will  cause  less  hemorrhage  than 
the  needle  with  cutting  edges, 
armed  with  a  doubled  silk  thread, 
giving  a  loop  about  eight  or  ten 
inches  long ;  he  inserts  it  opposite 
the  lowest  external  angle  of  the 


vivified  triangle,  (which  would  be 

a    little   above  the  level  of    the 

anus,)  and  makes  it  pass  across  the 

middle  of  the  united  bases  of  the 

triangles,   over   the  rectum,  and 

emerge  at  a  corresponding  point  on  the  opposite  side.     This  suture 

is  nowhere  visible  within  the  vagina,  for  it  lies  embedded  in  the 


Shows  surface  denuded,  and  sutures 
in  position. 


136  RUPTURE  OF  THE  PERINEUM. 

tissues  lying  over  the  rectum.  It  may  be  passed  by  one  sweep, 
or,  if  this  prove  difficult,  may  be  drawn  out  at  the  middle  of  its 
course,  and  reinserted  through  the  same  hole.  The  suture  with 
the  needle  attached  is  left  in  position,  and  another  being  taken,  it 
is  inserted  above  the  first,  and  made  to  pass  through  the  tissues 
at  the  extreme  upper  angle  of  the  vivified  surface.  Guided  by  the 
finger  in  the  rectum,  it  is  kept  embedded  in  the  recto- vaginal  sep- 
tum, and  emerges  at  a  point  on  the  other  side  corresponding  to  that 
of  entrance. 

This,  like  its  predecessor,  I  am  in  the  habit  of  concealing  in  the- 
tissues,  so  that  after  its  passage  it  is  nowhere  visil)le  within  the 
vagina.  This  is  not  customarj' ;  most  operators  leave  the  middle 
portion  of  each  suture  free  upon  the  surface.  I  believe  that  an 
embedded  suture  excites  much  less  irritation  on  the  deimded  sur- 
face, and  acts  less  like  a  seton  upon  it,  than  an  exposed  one. 

A  third  needle  is  now  inserted,  but,  instead  of  being  embedded,  it 
runs  across,  and  is  seen  traversing  the  vaginal  orifice.  It  is  inserted 
above  the  second  suture,  passes  into  the  vagina  at  the  inner  border 
of  one  triangle,  and  emerges  at  a  corresponding  point  on  the  oppo- 
site one.  Others  are  passed  in  the  same  way  until  the  operator 
feels  that  a  sufficient  number  are  in  place. 

If  he  intend  using  twisted  wire  sutures,  they  should  be  passed 
from  a  quarter  to  half  an  inch  from  the  edges  of  the  wound,  and  one- 
third  of  an  inch  apart;  if  the  quilled  suture,  the  wires  should  be 
inserted  three-quarters  of  an  inch  from  the  vivified  border,  and 
only  three  or  four  sutures  are  necessary. 

In  any  case  the  sutures  originally  passed  should  be  temporary 
ones,  only  intended  as  means  for  drawing  into  place  stronger,  perma- 
nent ones  of  silver,  silk,  or  hemp.  If  the  ordinary  quill  suture  is 
to  be  emploj^ed,  pieces  of  gum-elastic  catheter,  cane  or  bougie,  or 
rods  of  hard  rubber  are  inclosed  in  the  looped  extremity  of  the 
sutures,  the  opposing  surfaces  are  approximated  by  }  pressure,  the 
opposite  quill  is  put  into  position,  and  the  sutures  are  tied  over  it. 

What  appears  to  me  a  better  method  tlian  this,  for  employing 
this  form  of  suture,  is  one  which  has  been  extensively  used  by  Mr. 
James  Lane,  of  London,  Dr.  J.  H.  Thompson,  of  Washington,  and 
myself.  Whether  priority  belongs  to  Mr.  Lane  or  Dr.  Thompson 
I  cannot  say.  The  former  has  employed  it  since  I860,'  It  consists 
in  replacing  the  quills  by  little  rods  of  ivory,  (Lane,)  or  hard  rubber, 
(Thompson,)  perforated   by  three   or   four  holes   through   which 


'  Lancet,  Sept.  1865. 


OPERATION  FOR  PARTIAL  RUPTURE. 


137 


Fio-.  30. 


sutures  are  passed  and  secured.  Both  operators  employ  silver  sutures 
instead  of  silk.  Dr.  Thompson  secures  the  sutures  by  perforated 
shot:  Mr.  Lane  secures  them  by  some  method  which  he  does  not 
mention  in  the  account  which  I  have  seen  describing  his  operation. 
Mr.  Lane  reports  thirty  cases  thus  treated,  in  not  one  of  which  he 
failed  to  obtain  complete  cure.  Dr.  Thompson  reports  fifty-three, 
of  which  all  were  successful.  The  number  of  cases  operated  on  by 
myself  I  do  not  know,  but  it  is  quite  large,  and  I  cannot  recall  a 
failure. 

After  the  quills  are  arranged,  the  patient  is  put  to  bed,  quieted 
by  opium,  the  knees  tied  together,  the  bowels  kept  constipated,  (or 
in  a  lax  condition — Thompson,)  and  the 
urine  drawn  by  catheter  every  six 
hours.  On  the  third  day,  the  deep 
sutures  should  be  removed,  but  super- 
ficial ones,  which  are  inserted  to  the 
number  of  three  or  four  to  approximate 
the  cutaneous  surfaces,  should  be  left 
until  the  eighth. 

If  the  operator  intend  using  the 
interru})ted  wire  suture,  after  having 
passed  his  silk  sutures,  he  gives  their 
extremities  to  his  assistants,  and  taking 
a  piece  of  silver  wire  eight  inches  long 
affixes  it  to  the  loop  of  the  lowest  and 
draws  it  into  position.  It  is  then 
slightly  twisted,  so  as  to  keep  its  ends 
together,  and  bent  down,  so  as  to  be 
out  of  the  way,  and  another  is  drawn 
into  place,  and  so  he  proceeds  until  all 
are  placed.     Then  collecting  them,  he 

places  them  under  the  finger  of  one  of  his  assistants,  selects  the 
lowest,  or  that  first  passed,  adjusts  the  lips  of  the  w^ound,  removes 
blood  clots  from  betw^een  them,  and  putting  the  shield  in  place,  he 
twists  it  until  the  requisite  approximation  of  the  tissues  is 
accomplished.  For  the  details,  as  to  tlje  method  of  drawing  the 
wires  into  place  and  twisting  them,  the  reader  is  referred  to  the 
article  'on  Vesico-vaginal  Fistula.  After  the  plan  there  described, 
he  twists  them  one  after  tlie  other  from  below  upwards.  If  it 
appear  necessary,  superficial  sutures  are  then  passed  between  the 
deep  ones  to  approximate  the  cutaneous  surface  more  completely. 

All  the  twisted  sutures  should  then  either  be  cut  very  short  and 


Quill  sutures  in  place. 


J[38  RUPTURE    OF    THE    PERINEUM. 

turned  down  to  the  right  and  left  alternately,  or  be  left  long, 
collected  in  a  bundle,  and  tied.  The  object  of  this  is  to  keep  them 
from  sticking  into  the  neighboring  tissues.  The  patient  is  then 
put  to  bed ;  the  knees  are  tied  together  as  after  the  operation  b}- 
quill  suture ;  the  dorsal  or  lateral  decubitus  preserved ;  the  urine 
drawn  by  catheter  every  six  hours;  the  vagina  kept  clean  by 
syringing  with  tepid  water;  and  the  diet  made  nutritious,  though 
mild  and  unstimulating.  On  the  eighth  or  ninth  day,  the  sutures 
should  all  be  removed,  and  on  the  next,  the  bowels  should  be  acted  on 
by  a  saline  cathartic,  great  care  being  observed  to  prevent  tenesmus. 

Operation  for  Complete  Rupture. — Complete  perineal  laceration 
alwa3's  involves  rupture  to  a  greater  or  less  extent  of  the  anterior 
wall  of  the  rectum.  If  rupture  of  the  bowel  extend  for  more  than 
from  one  inch  to  an  inch  and  a  half  above  the  upper  edge  of  the 
sphincter  ani,  it  is  better  to  close  it  by  a  primary  operation  con- 
sisting of  vivifying  its  edges  and  uniting  them  down  to  the  anus. 
After  union  of  these  parts,  closure  of  the  perineum  may  be  practised. 
If  the  bovv^el  be  not  injured  above  an  inch  and  a  half  from  the 
sphincter,  one  operation  will  suffice  to  close  the  whole.  I  would 
not  be  understood  as  making  this  a  dogmatic  rule,  but  merely  one 
Avhicli  approximates  the  line  of  conduct  which  I  deem  safest. 

The  sole  object  of  the  operation  for  partial  rupture  is  restoration 
of  the  perineal  body.  The  objects  of  the  operation  for  complete 
rupture  are:  first,  restoration  of  the  sphincter  ani  muscle  to  all  its 
power  and  functions;  second,  closure  of  the  rectal  opening;  and 
third,  restoration  of  the  perineal  body.  What  constitutes  the 
main  object  in  the  first  operation,  is  the  least  of  those  striven 
after  in  the  second.  The  operator  must  then  appreciate  that  mere 
closure  of  the  rent  in  the  genital  fissure  is  not  what  is  desired. 
He  may  gain  this,  and  not  benefit  his  patient  in  the  least,  for 
incontinence  of  feces  and  gases  may  continue.  Success  involves 
always  complete  union  of  the  ends  of  the  severed  muscle  and  com- 
plete closure  of  the  rent  in  the  bowel.  To  secure  these  the  ends 
of  the  muscle,  spread  out  and  expanded,  must  be  curled  up  and 
approximated,  and  the  recto-vaginal  septum  must  be  drawn  down 
and  united  to  them.  With  these  facts  in  view,  clearly  defined  and 
appreciated,  the  difficulties  of  the  operation  greatly  diminish.  To 
no  one  are  we  so  much  indebted  for  their  demonstration  and  illus- 
tration by  practical  results,  as  to  Dr.  T.  Addis  Emmet,  of  this  city. 

Let  Fig.  31  represent  the  perfect  sphincter,  Fig.  32  will  show  it 
ruptured  and  spread  out,  with  \he  point  of  insertion  and  exit  of  tlic 
needles.     The  dotted  line  shows  the  course  of  the  metallic  sutures 


OPERATION    FOR    COMPLETE    RUPTURE. 


139 


embedded  in  the  tissue.  It  will  be  seen  that  the  remaining  recto- 
vaginal wall  is  a  fixed  point,  and  that  as  the  wire  is  twisted,  the 
ends  of  the  muscle  are  elevated,  and  the  three  points  approach  each 
other  as  shown  at  c.  As  the  twisting  goes  on,  these  points  come 
nearer  and  nearer  together  as  seen  in  Fig.  33,  until  at  last  they 
unite  as  shown  in  Fig.  34. 


Fiff.  31. 


Fig.  33. 


Fig.  34. 


Should  the  first  needle  be  inserted  and  drawn  out  above  the  end 
of  the  broken  muscle  as  shown  in  b  b,  Fig.  32,  the  tissues  at  this 
point  will  be  approximated,  and  the  ends  of  the  muscle  brought 
close  together,  but  absolute  and  complete  union  will  not  have  been 
attained,  and  loss  of  function  will  still  exist.  The  first  suture  is 
the  important  one,  and  must  catch  the  ends  of  the  broken  and 
expanded  muscle  so  as  to  lift  them  upwards  into  contact  with  each 
other  and  with  the  recto-vaginal  septum. 

In  vivifying  the  parts  before  insertion  of  the  needles  the  two 
lateral  triangles  representing  the  perineal  body  split  in  two  are 
denuded,  and  the  line  of  denudation  is  j^rolonged  backwards  along 
the  edge  of  the  recto-vaginal  septum.  The  border  of  the  rectal 
mucous  membrane  at  the  extremities  of  the  broken  muscle  as  far 
as  the  upper  end  of  the  rent  in  the  bowel  is  the  guide  for  doing  this. 

Fig.  35  is  a  schematic  diagram  showing  the  ruptured  bowel,  the 
expanded  muscle  at  its  anal  extremity,  the  insertion  and  exit  of 


140 


RUPTURE    OF    THE    PERINEUM. 


Fig.  35.  the  needles,  and  the  course  (dotted  lines)  of 

the  embedded  sutures.  The  line  of  denuda- 
tion is  marked  out  by  the  course  of  these 
sutures. 

The  rectal  rent  presents  itself  to  the  operator 
as  an  imperfect  isosceles  triangle,  apex  above 
and  base  below.  The  two  lateral  borders  of 
this  are  the  parts  to  be  vivified.  The  two 
basic  angles  are  on  a  lower  plane  than  that  of 
the  apex,  and  are  less  fixed  in  their  position. 
As  the  three  angles  are  acted  upon  by  the 
constricting  influence  of  the  encircling  su- 
ture, as  this  is  gradually  twisted,  the  two 
movable  basic  angles  are  elevated  to  the  plane 
of  that  of  the  apex  while  the  latter  is  by 
traction  drawn  down  to  meet  them.  Coinci- 
dently  the  denuded  sides  of  the  triangle  are, 
of  course,  approximated,  and  thus  the  rectal 
opening  is  completely  closed. 

To  sum  up  this  part  of  the  subject,  the  rule 
for  passing  the   first  suture   consists  in  the 
introduction  of  the  needle  as  low  down  as  the  lower  edge  of  the 

anus.  From  this  point  it  passes 
upwards  through  the  recto-vaginal 
septum,  completely  encircles  the  rec- 
tal rent,  and  comes  out  alongside  of 
the  lower  edge  of  the  anus  on  the 
opposite  side. 

Let  the  reader  refer  to  Fig.  36, 
and  he  will  appreciate  that  a  suture 
which  takes  this  course,  like  the 
string  at  the  mouth  of  a  bag,  puckers 
the  open  parts,  draws  them  into  ajv 
position,  and  controls  the  action  of 
the  sphincter.  The  two  conditions 
which  we  have  to  fear  as  sources  of 
failure  after  this  operation  are,  first, 
recto-vaginal  fistula,  and  second, 
non-union  of  the  sphincter.  This 
Surface  denuded  in  complete  peri-    method,  to  a  great  extent,  secures 

neal  rupture,  and  tirst  two  sutures  in      US  against  both, 
position. 


Fig.  36. 


VAGINISMUS.  141 

The  subsequent  steps  of  tliis  operation  are  the  same  as  those  of 
that  for  partial  rupture. 

Should  the  patient  tolerate  it,  a  rectal  tube  may  be  introduced 
occasionally  for  the  escape  of  air  from  the  bowel,  or  in  place  of 
this  a  large  catheter  may  be  kept  in  recto. 


CHAPTER    VI. 


VAGINISMUS. 


Definition. — This  affection  consists  in  a  peculiar  sensibility  or 
hypersesthesia  in  the  nerves  of  the  vaginal  mucous  membrane  at 
the  site  of  the  hymen,  which  upon  irritation  are  supposed  to  pro- 
duce spasmodic  contraction  in  the  sphincter  vaginae  muscle. 

Frequency. — Vaginismus  is  of  frequent  occurrence,  and  will  often 
be  met  with  in  practice.  It  has  received  little  notice  heretofore, 
not  because  of  its  rarity,  but  because  the  attention  of  practitioners 
has  not  been  specially  directed  to  it.  Dr.  Sims  declares  that  during 
twenty-four  months  he  met  with  it  seventeen  times,  and  during 
four  years  I  have  seen  thirteen  well-marked  cases. 

History. — The  fact  that  such  a  condition  occurs  and  becomes  a 
morbid  state  of  considerable  importance  was  known  to  Dupuytren, 
Roux,  and  Burns,^  of  Glasgow.  They  not  only  described  it,  but 
adopted  an  operative  procedure  which  has  since  been  revived,  and 
is  even  now  by  many  regarded  as  the  most  reliable  method  of  cure. 
Their  views  did  not  apparently  attract  much  attention,  nor  was  their 
import  really  appreciated  until,  at  a  later  period,  they  were  insisted 
upon  by  Professors  Simpson  and  Scanzoni.  BetAveen  August, 
1861,  and  October  of  the  same  year,  it  was  described  b}^  Debout,^ 
Michon,  and  Huguier,  and  just  afterwards  by  Marion  Sims,  who 
applied  to  it  the  appellation  which  I  have  adopted.  By  these 
authors,  incision,  subcutaneous  or  through  the  mucous  membrane, 
was  recommended,  in  imitation  of  earlier  investigators,  after  less 
severe  measures  have  failed  in  effecting  a  cure.  Since  the  time 
last  referred  to,  the  affection  has  been  allotted  a  space  in  the  various 
systematic  text-books  which  have  appeared  upon  gynecology. 


Simpson.  Clin.  Lcc.  Dis.  of  Women. 
Bui.  Geu.  de  Therap.  Med.  et  Chir.,  1861. 


142 


VAGINISMUS. 


Anatomi/  and  Pathology.— It  is,  I  think,  very  generally  accepted 
as  a  tact  that  tlie  bulbo-cavernosus  muscle  which  passes  over  the 
clitoris  and  forms  a  iigure-of-8  with  the  sphincter  ani  is  the  con- 
strictor vaginfe.  Dr.  Savage  denies  this  positively,  declaring  that 
"the  constriction  of  the  vaginal  ring  is  produced  by  the  puho- 

coccygeus   muscle."     This  is  a 
Fig.  37.  broad  and  powerful  muscle  sit- 

uated within  the  pelvis  just 
above  the  point  at  which  the 
vaginal  walls  branch  oft"  to  seek 
their  osseous  attachment.  Aris- 
ing from  the  inner  surface  of 
the  pubic  bones  its  fibres  take 
various  courses ;  its  median 
fibres  descend  by  the  side  of  the 
urethra  and  vagina,  some  of 
them  turning  in  between  the 
vasfina  and  rectum  to  meet  simi- 
lar  fibres  from  the  opposite  side 
in  the  perineal  body ;  another 
more  outward  series,  turning  in 
beneath  the  rectum,  intermix 
with  fibres  of  the  other  side ; 
while  the  remaining  fibres  still  more  outward  are  inserted  into 
the  sides  of  the  coccyx.     Fig.  37  shows  a  portion  of  this  muscle. 

Certain  morbid  states  produce-  so  great  a  degree  of  irritability 
in  the  nerves  supplying  the  vulva  and  lower  part  of  the  vagina,  that 
upon  contact  with  foreign  bodies  a  spasm  occurs  in  this  and  in 
neighboring  muscles,  which  constitutes  the  disease  that  now  en- 
gages us.  The  attention  of  some  has  been  chiefly  fixed  upon  the 
nervous  condition,  the  pubic  nerve  being,  according  to  tliem,  the 
seat  of  the  difficulty,  Avhile  others  have  especially  regarded  the 
resulting  muscular  spasm.  It  is  curious  to  perceive  how,  from 
different  standpoints,  both  parties  were  led  to  the  same  surgical 
resource. 

Causes. — This  affection  bears  to  the  vagina  the  same  relation 
which  blepharospasm  does  to  the  eyelids,  or  laryngismus  to  the 
larynx;  and,  like  those  affections,  is  not  ordinarilj'  a  primary  dis- 
order, but  one  which  results  from  some  special  local  cause.  It 
may  arise  from  excessive  nervous  irritability  affecting  the  whole 
system,  as  is  often  seen  in  hysterical  women,  or  be  produced  by 
some  local  disorder  of  apparently  insignificant  character.      Prof. 


Pubo-coccjg(His  muscle.     (Savage.) 


CAUSES.  143 

Willard  Parker'  reports  a  ease  wliicli  was  due  to  an  irritable  car- 
uncle of  the  meatus  not  larger  than  a  flaxseed,  removal  of  which 
resulted  in  cure.     In  other  words,  it  may  be  an  idiopathic  atiec- 
tion,  or  symptomatic  only  of  some  other  disorder. 
The  recoo-nized  causes  of  the  disease  are: 

The  hysterical  diathesis; 

Excoriations  or  fissures  at  the  vulva; 

Irritable  caruncle  of  the  meatus; 

Chronic  endometritis  or  vaginitis ; 

Pustular  or  vesicular  eruptions  on  the  vulva; 

Neuromata  ;^ 

Fissure  of  the  anus;^ 

Hyperesthesia  of  the  remains  of  the  hymen; 

An  abnormally  rigid  perineum; 

Disproportionately  large  size  of  male  organ. 

Professor  Scanzoni  in  August,  1868,  published  his  views  upon 
this  subject.  During  the  preceding  three  years  he  had  seen 
thirty-four  marked  cases,  due  chiefly,  he  thought,  to  violent 
eftorts  at  sexual  intercourse,  practised  upon  women  having  small 
vaginas  and  well-developed  hymens.  Scanzoni  found  that  twenty- 
five  of  his  thirty-four  patients  had  various  functional  and  organic 
difiiculties,  which  in  twenty  cases  had  come  on  after  marriage;  in 
eleven,  there  was  congestive  dysmenorrhoea ;  in  one,  amenorrhcea 
had  existed  for  three  years;  in  thirteen,  there  was  chronic  metritis; 
four  had  either  ante-  or  retroversion ;  in  one,  there  was  perimetritis  ; 
in  seventeen,  chronic  uterine  catarrh ;  in  fourteen,  vaginal  catarrh ; 
in  one,  anteflexion;  in  two,  retroflexion;  nine  had  urinal  difiicul- 
ties; one  had  inflammation  of  the  right  Bartholin's  gland;  in  four- 
teen, there  were  symptoms  of  anaemia;  and  in  seventeen,  of  hysteria. 
Although  the  sexual  act  could  not  be  fully  completed,  conception 
was  not  entirely  impossible,  as  out  of  the  thirty-four  cases  two  had 
conceived;  in  the  other  thirty-two,  sterile  marriages  had  existed 
from  one  to  eleven  years.  This  sterility  was  not  due  to  want  of 
sexual  desire,  but  arose  entirely  from  spasm  involving  all  the 
muscles  of  the  pelvis,  which  also  rendered  examination,  either  by 
the  touch  or  speculum,  impossible  without  the  use  of  an  anf^sthetic,^ 

Some  of  the  causes  which  I  have  enumerated  produce  vaginismus 

•  Bui.  N.  Y.  Acad.  Med.,  vol.  i.  p.  430. 

2  vSimpson,  Med.  Times  and  Gaz.,  1857,  vol.  i,  p.  336. 
^  H.  Dewees.     Baker  Brown. 

*  New  York  Med.  Journal,  vol.  ix,  p.  181. 


144  VAGINISMUS. 

by  direct  irritation  of  the  nerves  of  the  vaginal  mucous  membrane; 
others,  by  creating  a  discharge  which  indirectly  establishes  tlie 
same  condition. 

Dr.  William  Neftel,  of  this  city,  has  recently  published  some 
very  interesting  observations  uijon  the  influence  of  lead  poisoning 
in  creating  this  neurosis.  He  records  four  very  striking  cases, 
having  this  as  a  cause,  and  in  one,  tlie  vaginismus  was  the  symptom 
Avhich  incited  an  examination  for  poisoning  by  lead.  These  cases 
were  successfully  treated  by  electricity. 

Sijrnptoins  and  Physical  Signs. — The  patient  will  generally  com- 
plain of  excessivt3  pain  upon  sexual  intercourse,  the  mere  attempt 
at  which  will  throw  her  into  a  state  of  nervous  trepidation  and 
apprehension.  This  and  sterility  will  probably  be  all  that  will 
have  attracted  her  attention,  though  in  some  cases  a  marked 
tendency  to  spasm  will  have  been  noticed  upon  sudden  changes 
of  position,  or  washing  the  genital  fissure.  One  or  more  of  these 
symptoms  will  call  for  a  physical  exploration,  when  the  following- 
facts  will  be  recognized.  As  soon  as  the  finger  is  brought  into 
contact  with  the  site  of  the  hymen,  the  patient  will  probably 
spring  from  her  place,  comi^lain  of  agonizing  pain,  and  evince 
great  nervous  disturbance.  Should  the  examination  l)e  persisted 
in,  introduction  of  the  finger  will  be  found  to  be  almost  impossible, 
and  if  it  be  forced  into  the  canal,  a  violent  muscular  contraction 
will  be  perceived.  If,  instead  of  the  finger,  a  camel's  liair  brush 
or  a  feather  be  employed,  severe  pain  and  contraction  will  follow 
even  this  ai)plication  to  the  surface. 

Difereniiation. — There  is  no  other  affection  with  which  this  can 
be  confounded.  All  that  it  will  be  necessary  to  decide  concerning 
it,  will  be  whether  it  is  an  idiopathic  or  a  symptomatic  disorder. 

Course  and  Dvraiion. — In  its  duration  it  is  unlimited.  Cases  are 
recorded  in  which  it  lasted  for  twenty-five  and  tliirty  years,  and 
unless  relieved  by  art,  it  will  probably,  in  its  worst  forms,  become 
a  permanent  condition.  In  its  less  severe  type,  and  more  particu- 
larly when  dependent  upon  some  other  diseased  state,  it  may  often 
l>e  relieved  by  mild  means,  or  pass  away  Avithout  treatment. 

Prognosis.— ''Yvom  personal  experience,"  remarks  Dr.  Sims,  "T 
can  confidently  assert  that  I  know  of  no  disease  capable  of  produc- 
ing so  much  unhappiness  to  both  parties  to  the  marriage  contract, 
and  I  am  happy  to  state  that  I  know  of  no  serious  trouble  that  can 
be  so  easily,  so  safely,  and  so  certainly  cured." 

The  experience  of  Scanzoni,  Tilt,  and  others,  who  have  adopted 
an  entirely  difl'erent  treatment  from  that  pursued  by  the  last-men- 


TREATMENT. 


145 


tioiied  author,  and  who  deprecate  the  use  of  the  knife,  leads  them 
to  the  same  favorable  conclusion.  In  my  own  experience  I  have 
met  with  no  case  in  which  I  have  not  been  able  to  give  relief,  either 
by  operative  interference,  or  by  tiie  complete  removal  of  the  disease 
of  which  this  condition  was  a  symptom. 

Treatment. — Careful  search  should  be  made,  before  the  adoption 
of  treatment,  for  the  cause  of  the  affection.  Should  this  be  dis- 
covered, hope  may  be  entertained  that  its  removal  will  effect  a 
cure.  Should  no  cause  be  discovered,  or  its  treatment  not  be 
followed  by  recovery,  the  general  state  of  the  patient  should  be 
altered  and  improved  by  exercise,  change  of  air  and  S(,'ene,  vege- 
table and  mineral  tonics,  sea  bathing,  and  cheerful  society.  Riding 
on  horseback  has  been  especially  advised,  but  rowing,  bowling, 
walking,  or  any  other  exercise  which  develops  the  system  and 
improves  the  tone  of  the  nervous  organism,  will  probably  answer 
as  well.  Local  treatment  calculated  to  soothe  the  excited  vaginal 
nerves  should  then  be  resorted  to.  The  free  use  of  vasrinal 
injections  containing  laudanum,  creasote,  or  acetate  of  lead  is 
sometimes  productive  of  good.  Dr.  Peaslee  speaks  highly  of  an 
ointment  composed  of  two  grains  of  atropine  to  an  ounce  of  lard. 
This  alkaloid,  or  the  extracts  of  opium,  belladonna,  hyoscyamus, 
or  stramonium,  may  be  incorporated  in  an  ointment  or  in  sup- 
positories, and  applied  freely  to  the  sensitive  part.  In  some  cases 
suppositories  containing  from  five  to  ten  grains  of  iodoform  prove 
very  beneficial.  At  the  same  time  the  glass  tube,  represented  in 
Fig.  38,  should  be  gently  inserted  into  the  vagina,  and  kept  there 

Fig.  38. 


Sims's  vaginal  dilator. 


for  as  many  hours  a  day  as  practicable.  Its  presence  will  tend  to 
benumb  the  nervous  sensiljility,  distend  the  vagina,  and  produce 
a  tolerance  of  foreign  bodies.  During  this  treatment  the  patient 
should  live  apart  from  her  husband.  This  plan  of  treatment, 
simple  as  it  is,  combined  with  copious  vaginal  injections  used 
night  and  morning  for  the  complete  removal  of  irritating  dis- 
charges, as  well  as  for  their  own  direct  sedative  effects,  will  often 
10 


146  VAGINISMUS. 

prove  eftectiial  and  avoid  tlie  necessity  for  a  surgical  procedure  of 
some  gravity. 

That  tlie  operation  proposed  by  Dr.  Sims  for  the  cure  of  this 
condition  is  eifectual  there  can  be  no  doubt.  I  have  myself  resorted 
to  it  in  a  number  of  very  aggravated  cases,  and  in  all  with  perfect 
success.  But  there  has  been  for  some  time  in  the  minds  of  many 
gynecoloo-ists  a  growing  distrust  of  the  necessity  of  a  resort  to  a 
procedure,  which  is  reported  in  one  case  to  have  resulted  in  fatal 
hemorrhao-e.  In  many  cases,  even  of  grave  character,  it  has  been 
proved  that  by  distention  of  the  vagina,  either  with  the  fingers  or 
by  expanding  instruments,  and  subsequent  maintenance  in  the 
canal  of  a  vaginal  plug,  cure  can  be  accomplished  as  perfectly  and 
even  as  rapidly  as  by  the  cutting  method.  Two  eminent  authori- 
ties, Scanzoni  and  Tilt,  liave  especially  advocated  this  plan  and 
opposed  the  operation  of  Sims.  Their  views,  as  reported  in  recent 
journals,  I  here  place  before  the  reader. 

"  Of  more  than  100  cases  that  liave  fallen  under  Scanzoni's  observa- 
tion, in  times  past,  he  has  been  completely  suecessfnl  in  the  treatment 
of  all  to  which  he  was  able  to  give  his  personal  attention,  without  in  a 
single  case  having  recourse  to  the  knife.  The  first  condition  of  success 
is  complete  sexual  abstinence;  for  the  first  three  or  four  days,  a  tepid 
sitz-bath  should  be  used  night  and  morning;  warm  local  bathing,  with 
aq.  Goulardi,  or  the  same  applied  Avith  lint,  several  times  a  da}^  Defe- 
cation must  be  regulated,  and  friction  from  motion  carefullj'  avoided. 
After  a  few  daj-s,  the  sensibility  of  the  parts  will  be  so  much  allayed 
that  a  solution  of  arg,  nit.,  x-xx  grs.  to  5j  of  water,  may  be  applied 
with  a  brush.  After  about  eight  days'  continuance  of  this  treatment, 
vaginal  suppositories  of  ext.  belladonna  and  cacao-butter  may  be  placed 
behind  the  hymen,  and  in  contact  with  it,  daily.  These  remedies,  either 
alternately  or  simultaneously,  must  be  continued  until  ever}'  trace  of 
inflammation  has  disappeared,  and  the  normal  sensibility  is  restored. 
Generally  two  or  three  weeks  will  be  required  to  attain  these  objects. 
Then  dilatation  must  be  commenced;  but  for  this  jjurpose  sponge-tents 
are  useless.  A  graduated  series  of  glass  conical  specula  are  best  adapted 
to  this  object.  After  the  first  slightly  painful  attempt,  the  patient 
generally  will  be  able  to  introduce  it  with  facility,  and  it  may  be  allowed 
to  remain  from  one-half  to  one  hour.  Even  when  the  hymen  remains, 
it  will  not  be  necessary  to  incise  it,  as  dilatation  can  be  effected  without 
recourse  to  that  measure.  At  first,  the  dilator  may  be  used  every  two 
or  three  days,  then  every  day  or  twice  a  day  for  two  or  three  hours, 
gradually  increasing  the  size  of  the  dilator  until  the  object  shall  have 
been  attained,  which  in  some  instances  may  require  an  instrument  ad- 
mitting dilatation,  as  that  of  Segalas.     Sitz-baths,  belladonna,  and  pen- 


SIMS'S    OPERATION.  147 

cilling  with  nitrate  of  silver  may  be  required  from  time  to  time,  and  the 
cure  will  usually  be  completed  in  from  six  to  eight  weeks.  It  will  be 
seen  that,  although  the  treatment  of  Sims  is  attended  with  an  equally 
satisfactory  result,  it  is  of  a  much  more  serious  character  than  the  treat- 
ment adopted  by  Scanzoni ;  and,  after  the  operation,  the  success  of  the 
treatment  dei)ends  generall3^  upon  the  subsequent  dilatation.  The  time 
required,  moreover,  is  nearly  the  same  by  either  process.'" 

Dr.  Tilt  takes  the  same  position  iu  deprecating  resort  to  the 
knife  and  giving  preference  to  forcible  distention.  He  anaesthe- 
tizes his  patient,  and  introducing  both  thumbs,  back  to  back, 
forcibly  distends  the  ostium  vaginae  for  five  or  six  minutes.  He 
then  keeps  a  large  vaginal  plug  in  situ  by  a  T  bandage  for  a  num- 
ber of  days.  This  author  lays  especial  stress  upon  the  necessity, 
already  alluded  to,  of  first  removing  any  existing  uterine  or 
vaginal  disease,  in  the  hope  of  simultaneously  curing  the  secondary 
trouble,  before  having  recourse  even  to  the  process  of  distention. 

Should  these  means  fail,  the  operation  of  removal  of  the  hymen  and 
section  of  the  perineal  body  may  be  practised.  It  will  be  observed 
that  I  do  not  say  of  the  sphincter  vaginae  muscle.  This  is  certainly 
not  severed  to  any  extent ;  and  it  is  highly  probable,  if  we  accept 
Dr.  Savage's  anatomy  of  it,  that  its  fibres  are  nowhere  involved  in 
the  section.  My  impression  is,  that  Sims's  operation  accomplishes 
two  things :  first,  ablation  of  the  hymen  often  removes  nerves 
which  are  in  a  condition  of  hyperaesthesia ;  second,  section  through 
the  perineum  enlarges  the  ostium  vaginae,  and  thus  removes  an 
obstacle  to  intercourse. 

If  I  be  correct  in  this,  we  have  here  an  instance  of  the  injury 
done  by  theorizing  with  reference  to  a  subject  which  should  be  put 
beyond  doubt  by  anatomical  demonstration  on  the  cadaver.  No 
one  would  have  done  mischief,  if  told  to  enlarge  the  ostium  vaginae 
by  section ;  many  have  caused  serious  hemorrhage  by  endeavoring 
to  sever  the  bulbo-cavernosus  muscle ;  which  good  authorities 
declare  to  be  no  sphincter  at  all. 

Sims's  Operation. — The  patient  having  been  anaesthetized,  and 
placed  on  the  back,  upon  a  table,  the  remains  of  the  hymen  are 
entirely  excised  by  a  pair  of  curved  scissors.  The  slight  hemor- 
rhage resulting  from  this  will  soon  cease  under  the  application  of 
a  compress  wet  with  ice  water,  or  of  a  solution  of  the  persulphate 
of  iron. 

The  index  and  middle  fingers  of  the  left  hand  are  then  passed 

'  N.  Y.  Med.  Journal,  loc.  cit. 


148  VAGINISMUS. 

into  the  vagina,  so  as  to  put  the  fourchette  on  the  stretch.  By 
means  of  a  scalpel  a  deep  incision  is  then  made  on  the  right  of 
the  mesial  line,  terminating  at  the  raphe  of  the  perineum.  A 
similar  incision  is  then  made  on  the  other  side,  the  two  being 
united  at  the  raphe,  and  extended  to  the  perineal  integument  and 
through  its  upper  border.  Each  of  these  incisions  will  extend  from 
about  half  an  inch  above  the  upper  border  of  the  sphincter,  (mean- 
ing evidently  the  bulbo-cavernosus,)  to  the  perineal  raphe,  thus 
passing  across  the  muscle,  and  measuring  nearly  two  inches. 

After  this,  the  vaginal  dilator  is  placed  in  the  canal,  and  worn 
for  two  hours  in  the  morning,  and  three  or  four  in  the  evening, 
according  to  the  tolerance  for  it  which  is  manifested.  Fig.  38 
represents  the  glass  vaginal  dilator,  which  is  three  inches  long, 
slightly  conical,  open  at  one  end  and  closed  at  the  other,  and  vary- 
ins:  in  size  from  an  inch  to  an  inch  and  a  half  in  diameter.  This 
instrument  is  kept  in  place  by  a  T  bandage,  and  should  be  worn 
for  two  or  three  weeks. 

Burns's  operation,  more  recently  endorsed  and  practised  by  Sir 
James  Simpson,  rests,  it  appears  to  me,  upon  too  weak  a  basis  to 
warrant  its  use.  It  consists  in  section  of  the  pudic  nerve,  which  Sir 
James  says  "  may  be  exposed  by  cutting  through  the  skin  and  fascia, 
at  the  side  of  the  labium  and  perineum;  beginning  on  a  line  with  the 
front  of  the  vaginal  orifice,  and  carrying  the  incision  back  for  two 
inches.  The  nerve,  being  blended  with  cellular  suljstance,  is  not 
easily  seen  in  such  an  operation;  but  it  may  be  divided  by  turning 
the  blade  of  the  knife  and  cutting  through  the  vagina  to  its  inner 
coat,  but  not  injuring  that.  It  may  be  more  easily  divided  by  cut- 
ting from  the  vagina.  Slitting  merely  the  orifice  of  the  vagina  will 
not  do ;  we  must  carry  the  incision  fully  half  an  inch  up  from  the 
orifice,  and  also  divide  the  mucous  membrane  freely  in  a  lateral 
direction."  Now  let  the  reader  examine  Savage's  plate,  showing 
the  pudic  nerve,  and  he  will  see,  that  to  sever  it  "by  cutting  from 
the  vagina,"  the  incision  would  have  to  be  carried  as  far  as  the 
ramus  of  the  ischium  on  each  side,  where  it  lies  in  direct  contact 
with  the  pudic  artery. 

ISTo  one  can  examine  a  diagram  showing  the  course  of  this  nerve, 
without  strongly  suspecting,  that  its  section  is  an  operation  which 
has  existed  in  the  mind  of  the  operator,  and  never  really  been  per- 
formed upon  the  living  being. 

Upon  what  then  did  this  procedure  rest  for  its  good  eifects? 
Upon  the  same  basis  as  that  for  the  supposed  section  of  the  sphinc- 


OPERATIONS    FOR    VAGINISMUS.  149 

ter;  severance  of  the  tissues  at  the  ostium  vaginae  and  consequent 
enlargement  of  the  entrance  to  the  vagina. 

The  practice  which  I  should  recommend  in  vaginismus,  with  the 
light  which  we  at  present  have  for  our  guidance,  is  the  following: 

1st.  Remove  existing  uterine,  ovarian,  vaginal,  urethral,  or  rectal 
disease,  if  any  can  be  discovered;  insist  upon  the  patient's  living 
absque  marito  ;  let  her  use  copious  vaginal  injections  of  warm  water 
twice  daily;  use  the  local  anodynes  mentioned,  by  rectal  or  vaginal 
suppository,  or  throw -into  the  vagina,  every  night,  by  means  of  a 
small  syringe,  four  drachms  of  fluid,  in  which  are  dissolved  twenty 
or  thirty  grains  of  chloral ;  have  a  plug  inserted  into  the  vagina  by 
the  patient  and  retained  for  several  hours  every  day;  give  such 
tonics  as  quinine,  strychnine,  and  iron  freely;  and,  if  it  can  be 
accomplished,  let  the  patient  have  a  change  of  air  and  scene,  and 
indulge  in  sea  bathing. 

2d.  Should  this  plan  fail,  anaesthetize  the  patient,  and  by  means 
of  the  blades  of  a  trivalve  or  quadrivalve  speculum,  distend  the 
ostium  vaginae  thoroughly;  follow  this  by  the  use  of  the  vaginal 
plug,  and  resort  to  the  means  above  given  for  locally  soothing  and 
generally  sustaining. 

3d.  Should  this  method  likewise  fail,  antesthetize  the  patient; 
remove  the  hymen  by  scissors,  a  simple  procedure ;  incise  the  peri- 
neal body  exactly  as  it  is  torn  in  parturition,  introduce  the  plug, 
and  keep  it  in  situ  for  a  week,  removing  it  and  cleansing  it  daily. 
After  this,  let  the  patient  use  it  herself,  and  follow  out  the  direc- 
tions given  under  my  first  caption. 

The  act  of  parturition  would  be  ver^^  likely  to  remove  this  con- 
dition entirely,  but  unfortunately  one  of  the  most  constant  of  the 
results  of  vaginismus  is  sterility.  This  arises  from  the  fact  that 
sexual  intercourse  is  so  painful  that  it  is  imperfectly  performed, 
or,  as  is  more  commonly  the  case,  all  efibrts  at  overcoming  the 
obstacle  to  it  cease,  and  the  woman  lives  a  single  life.  Should 
this  state  of  things  be  found  to  exist,  the  patient  may  be  thoroughly 
anaesthetized,  in  the  hope  that  complete  connection,  accomplished 
under  these  circumstances,  may  result  in  pregnancy. 

For  a  number  of  interesting  cases  of  this  character  the  reader  is 
referred  to  Dr.  Sims's  work  upon  Uterine  Surgery. 


150  VAGINITIS. 


CHAPTER   VII. 

VAGINITIS. 

Definition  and  S^/nonyms.— The  mucous  membrane  lining  the 
vagina  is  subject  to  inflammatory  action,  which  receives  tlie  name 
of  vao-initis.  It  is  the  same  disease  which  by  certain  authors  has 
been  described  under  the  titles  of  vaginal  leucorrhoea,  blennorrhoea, 
and  blennorrhagia. 

Anatomy  of  the  Vagina. — The  vagina  is  a  canal  formed  of  strong, 
muscular  elements  and  lined  by  mucous  membrane.  At  its  upper 
extremity  it  is  attached  to  the  cervix  uteri,  with  which  it  unites  at 
a  variable  point,  l)ut  usually  midway  between  the  os  internum  and 
OS  externum.  This  canal  consists  of  three  coats:  1st,  an  outer  coat, 
formed  of  fibrous  and  elastic  tissue;  2d,  a  middle  coat,  formed  of 
unstriped  muscular  fibre  and  fibre-cell,  which  are  subject  like  the 
same  structures  in  the  uterus  to  great  hypertrophy  during  utero- 
gestation  ;  and,  3d,  an  inner  coat  or  lining  mucous  membrane,  com- 
posed of  connective  tissue  and  elastic  fibre,  and  covered  over  with 
squamous  epithelium.  The  3d  extends  to  the  fourchette;  the  1st 
and  2d  spread  out  at  the  upper  portion  of  the  perineum,  making 

the  perineal  septum,  and  attach  them- 
e's- ^^-  selves  to  the  ischio-pubic  rami.  Its  general 
form  has  been  aptly  likened,  by  Dr.  Sav- 
age,' to  that  which  would  be  assumed  by 
a  flexible  tube  if  shortened  to  nearly  half 
its  length  by  a  cord  passed  from  end  to 
end  through  one  of  its  sides.  The  ridge 
thus  formed  is  called  the  anterior  column 
„.,.„             .,,       „  ^^  ofthe  vagina, and  marks  the  vesico-vao^inal 

Filiform    papillffi  of  the  va-  o        '  ^  c?     _ 

gina.    (Kiiian.)  scptum.    It  is  about  two  inchcs  long,  while 

the  posterior  wall,  the  posterior  column, 
as  it  is  called,  is  twice  that  length.  The  anterior  column,  or  cord, 
which  shortens  the  vagina,  puckers  its  investing  mucous  mem- 
brane and  throws  it  into  folds  or  rugae,  which  run  transversely 

'  Op.  cit. 


SIMPLE     VAGINITIS.  151 

towards  the  posterior  column.  This  mucous  membrane  is  studded 
with  papilke,  which  are  covered  by  pavement  epithelium.  The 
papillae  of  the  vagina,  which  were  first  fully  described  by  Dr.  Franz 
Kilian,  were  regarded  by  him  as  having  for  their  function  the 
transmission  of  sensation.  He  represents  them  as  being  thread-like 
and  filiform,  as  shown  in  Fig.  39. 

Much  discussion  has  occurred  among  anatomists  as  to  the  pre- 
sence of  muciparous  glands  between  the  folds  of  the  vaginal  mucous 
membrane,  some  asserting  and  others  as  positively  denying  their 
existence.  The  researches  of  Huschke,  Jarjavay,  Jamain,  Farre, 
and  other  eminent  investigators,  enable  us  to  accept  their  existence 
as  an  undoubted  fact,  though  it  is  curious  that  Charles  Robin^  and 
Sappey^  have  been  unable  to  discover  them.  The  vagina  may 
then  be  said  to  be  lined  by  a  mucous  membrane  which  is  covered 
by  epithelium,  and  thrown  into  folds  which  are  studded  by  pro- 
jecting, filiform  papillae,  between  which  lie  numerous  muciparous 
follicles. 

Varieties  of  Vaginitis. — Vaginitis  assumes  three  forms,  Avhich 
differ  from  each  other  sufficiently  to  require  separate  investigation. 
They  are  denominated  as  follows : 

Simple  vaginitis ; 

Specific  vaginitis ; 

Granular  vaginitis. 

Prof.  Hildebrandt,  of  Germany,  has  recently  described  another 
variety  which  he  styles  "  adhesive,"  for  the  reason  that  its  chief 
characteristic  is  to  produce  adhesions  between  the  vagina  and  uterus. 
It  occupies  the  upper  third  of  the  vagina ;  the  mucous  membrane 
bleeds  readily ;  and  the  discharge  is  thick,  creamy,  and  sanguinolent. 

Simple  Vaginitis. 

Definition. — This  variety  of  vaginitis  consists  in  inflammation  of 
the  mucous  membrane  of  the  vaginal  canal  from  some  cause  other 
than  gonorrhoeal  contagion. 

Varieties. — It  may  exist  in  acute  or  chronic  form,  either  of 
which  types  may  appear  originally  or  be  the  result  one  of  the 
other.  The  acute  form  may  be  excited  by  some  special  cause  and 
rapidly  pass  into  the  chronic ;  or,  originating  as  a  low  grade  of 
inflammation,  the  disease  may  at  any  time  take  on  the  characters 
of  virulence  and  acuity.  Two  subdivisions  of  simple  vaginitis, 
the  recognition  of  which  at  the  bedside  constitutes  an  important 
point,  are,  primary  and  secondary.     Sometimes  the  disease  exists 


'  Nysten's  Dictionary.  ^  Descriptive  Anatomy. 


152  VAGINITIS. 

as  a  primary  lesion,  but  very  commonly  it  depends  upon  the  ex- 
coriating properties  of  a  fluid  discharged  by  the  mucous  membrane 
of  the  uterus.  Under  ttiese  circumstances  no  treatment  addressed 
to  the  vaginal  surface  will  eifect  a  cure,  for  even  if  the  disorder 
existing  there  be  removed,  it  must  inevitably  return  so  long  as 
the  cause  which  originally  produced  it  remains. 

Causes. — In  the  great  majority  of  instances  this  afl'ection,  more 
particularly  in  its  chronic  form,  depends  upon  a  discharge  from 
the  uterus,  to  which  it  is  secondary.  It  may,  however,  arise  from 
any  of  the  following  exciting  influences  : 

Exposure  to  cold  and  moisture; 
Injury  from  })essaries  or  coition  ; 

Disordered  blood  states,  as  those  of  phthisis  and  the  exan- 
themata ; 
Retained  and  putrefying  secretions  ; 
Chemical  agents ; 
Parturition. 

After  matrimony  the  acute  form  is  not  unfrequently  excited, 
and  in  prostitutes,  whose  occujDation  involves  an  abuse  of  sexual 
intercourse,  it  is  quite  common. 

A  bit  of  sponge,  or  other  substance  which  retains  the  natural 
secretions,  left  in  the  vagina  until  putrefaction  occurs,  will  often 
induce  the  affection,  and  three  of  the  most  virulent  cases  that  I 
have  ever  seen  were  caused  hy  contact  of  a  solution  of  chromic 
acid  with  the  vaginal  walls  in  making  an  application  to  the  uterus. 

Pathology. — At  the  commencement  of  the  disease,  the  mucous 
membrane  of  the  vagina  becomes  highly  vascular  and  its  arterioles 
distended.  There  is  a  rapid  moulting  of  ej)ithelium,  so  that  abra- 
sions often  exist,  and  at  times  follicular  ulcerations  and  diphtheritic 
deposits  make  their  appearance.  Sometimes,  though  rarely,  the 
epithelial  lining  of  the  vagina  is  thrown  off"  entire,  constituting  a 
cast  or  mould  of  the  canal  very  similar  in  character  to  the  d}' smen- 
orrhccal  membrane  wliich  is  occasionally  expelled  from  the  uterus. 

In  very  severe  cases  the  inflammatory  action  passes  down  into 
the  submucous  tissues  and  a  true  phlegmonous  process  is  estab- 
lished which  may  result  in  abscess.  For  a  period  varying  from 
fifteen  to  thirty  hours  after  the  inception  of  the  disease,  the  natural 
secretion  of  the  part  is  checked  ;  then  there  pours  forth  freely  pus 
of  acrid  and  offensive  character,  which,  in  a  week  or  ten  days,  is 
replaced  by  muco-purulent  material.  This  discharge  is  found  to 
consist  of  serum,  large  numbers   of  epithelial   cells,  pus,  blood- 


SIMPLE    VAGINITIS. 


153 


o-lobules,  and  an  infusorial  animalcule  called  the  trichomonas  vas-- 
inalis  by  M.  Donn^,  who  first  described  it.  By  some  the  last  has 
been  regarded  as  ciliated  epithelium  separated  from  the  uterus, 
but  it  is  probably  an  animalcule  which  exists  in  vaginal  mucus  of 
unhealthy  character.  M.  Donne  at  first  regarded  it  as  characteristic 
of  specific  vaginitis,  but  subsequently  renounced  the  view. 

Symptoms. — Acute  vaginitis  manifests  itself  by  the  following 
symptoms : 

A  sense  of  heat  and  burning  in  the  vagina ; 

Aching  and  weight  at  the  perineum  ; 

Frequent  desire  for  micturition  ; 

Profuse  purulent  leucorrhooa  of  ofl:ensive  character ; 

Violent  pelvic  pain  and  throbbing; 

Excoriation  of  the  parts  around  the  vulva. 

In  the  chronic  form  the  disease  shows  the  same  symptoms, 
though  with  much  less  severity.  In  very  mild  cases,  only  a  slight 
itching  or  burning  sensation  is  experienced,  with  discharge  of  leu- 
corrhoeal  matter. 

Physical  Signs. — When  the  inflammation  is  acute  the  labia  are 
found  swollen  and  tense,  the  mucous  membrane  of  the  vaginal 
canal  red  and  covered  with  pus,  and  the  animal  heat  very  much 
increased.  Introduction  of  the  finger  produces  great  pain,  and 
often  cannot  be  tolerated.  As  the 
labia  are  separated  a  flow  of  fetid 
muco-pus  is  discharged.  If  the  canal 
be  explored  by  means  of  the  specu- 
lum, its  surface  will  be  found  con- 
gested, while  at  numerous  points 
abrasions,  and  perhaps  follicular  ul- 
cerations, will  be  noticed.  The  in- 
flammatory appearances  of  the  vagina 
will  be  seen  to  have  extended  to 
the  cervix  uteri,  and  very  generally 
from  the  os  will  be  found  to  hang 
a  plug  of  mucus  secreted  by  the  irri- 
tated, or  even  inflamed,  Nabothian 
follicles. 

Prognosis. — In  its  acute  form  it 
usually  runs  its  course  in  about  two 
weeks.  In  the  chronic  form  it  lasts  for  an  indefinite  time,  often 
subsiding  into  ordinary  vaginal  leucorrhcea,  or  rather  into  a  state 
of  which  this  is  the  only  prominent  symptom. 


Fio-.  40. 


Epithelinni  in  all  stages  of  devel- 
opment, in  simple  vaginitis.  220 
diameters.     (T.  Smith.) 


154  VAGINITIS. 

Differentiation. — Simple  vaginitis  may  be  confounded  with — 
Gonorrhoea ; 
Endometritis ; 
Pelvic  abscess ; 
Granular  degeneration  of  cervix. 

From  the  first  the  differentiation  is  always  difficult  and  fre- 
quently impossible.  The  means  by  w^hich  it  may  sometimes  be 
accomplished  will  be  mentioned  in  the  article  relating  to  Specific 
Vaginitis.  From  the  three  remaining  aifections  it  is  readily  dis- 
tinguishable by  the  speculum  and  vaginal  touch.  An  error  will  be 
committed  only  when  the  practitioner  is  not  mindful  of  the  possi- 
bility of  its  occurrence,  and  draws  his  conclusions  from  insufficient 
data.  I  have  seen  two  cases  of  profuse  and  obstinate  vaginal  dis- 
charge regarded  as  the  result  of  vaginitis,  which  were  in  reality 
produced  by  pelvic  abscesses  that  emjitied  their  contents  into  the 
upper  part  of  the  canal.  An  element  in  such  cases  calculated  to 
mislead  a  superficial  examiner  is  the  fact  that  vaginitis  does  really 
exist  to  a  limited  extent  as  a  result  of  the  purulent  fiow  from  the 
abscess.  This  remark  likewise  holds  true  in  reference  to  endome- 
tritis and  granular  degeneration. 

Complicatioris. — Vaginitis  sometimes  produces  violent  urethritis, 
and  less  frequently  results  in  endometritis,  Fallopian  salpingitis, 
and  pelvic  peritonitis. 

Specific  Vaginitis,  or  Gonorrhoea. 

Definition. — This  variety  of  the  affection  consists  in  inflammation 
of  the  vulva,  vagina,  and  urethra,  arising  from  a  specific  contagion 
which  is  transmitted  by  a  yellow,  purulent  discharge. 

Pctthology. — The  purulent  material  which  is  the  contagious  ele- 
ment, after  remaining  for  some  time  in  contact  with  the  vaginal 
walls,  excites  in  their  investing  mucous  membrane  an  active  hyper- 
asmia  which  results  in  heat,  swelling,  pain,  and  an  ichorous  and 
abundant  purulent  secretion.  This  inflammation  may  be  simulated 
by  simple  acute  vaginitis,  but  its  most  characteristic  features  are 
usually  excited  by  the  contagious  influence  just  alluded  to.  The 
disease  may  affect  all  the  localities  above  mentioned  at  the  same 
time,  but  very  often  it  is  limited  to  the  upper  part  of  the  vagina, 
to  the  vulva,  or  to  the  urethra.  In  some  cases  it  is  for  a  length  of 
time  concealed  in  the  vaginal  cul-de-sac,  no  other  part  of  the 
vagina  being  affected.  This  fact  explains,  says  Alphonse  Gu^rin,i 
how  women  apparently  healthy  transmit  gonorrhoea. 

'  Maladies  des  Organes  Genitaux,  p.  285. 


SPECIFIC     VAGINITIS,    OR    GONORHUCEA.  155 

Causes. — As  there  is  but  one  cause  for  scarlet  fever,  for  measles, 
and  for  variola,  namely,  absorption  of  a  specific  poison  or  conta- 
gious material,  so  is  there,  it  appears  to  me,  but  one  cause  for 
gonorrhoBa.  It  is  true  that  simple  acute  vaginitis  may  simulate 
gonorrhoea  so  closely  that  the  most  experienced  observer  will  be 
foiled  in  diagnosis,  but  this  fact  does,  not  prove  the  diseases  to  be 
identical.  The  poison  of  gonorrhoea  produces  infiammatory  re- 
sults as  a  certain  consequence  of  contact ;  the  causes  of  acute  vagi- 
nitis produce  them  as  an  accident  which  probably  in  a  difterent 
state  of  the  patient's  system  would  not  have  occurred.^ 

Symptoms. — The  symptoms  of  this  variety  of  vaginitis  differ 
very  little,  indeed  in  many  cases  not  at  all,  from  those  of  the 
simple  acute  form.     They  may  be  thus  enumerated : 

Heat  and  burning  in  the  vagina ; 

Acliing  and  sense  of  weight  at  the  perineum ; 

Frequent  desire  for  micturition  ; 

Scalding  in  the  passage  of  urine  ; 

Profuse  purulent  leucorrhoea  of  offensive  character ; 

Violent  pelvic  pain  and  throbbing ; 

Excoriation  of  the  parts  around  the  vulva. 

Physical  Signs. — The  vulva,  vagina,  and  urethra  will  be  found 
swollen,  tense,  red,  and  hot.  In  the  beginning  they  are  unnatu- 
rally dry,  but  very  soon  a  profuse  secretion  bathes  them  with  a 
creamy  pus,  sometimes  streaked  with  blood.  Should  the  affec- 
tion have  exerted  its  influence  chiefly  upon  the  vulva,  pruritus, 
excoriation,  and  intense  heat  will  be  observed.  Should  the  urethra 
be  chiefly  or  solely  diseased,  instances  of  which  are  recorded  by 
Ricord  and  Cullerier,  the  most  violent  scalding  upon  the  passage 
of  urine  will  especially  annoy  the  patient. 

Differentiation. — It  will  be  seen,  from  what  has  been  already 
stated,  that  the  differentiation  of  this  disease  from  simple  acute 
vaginitis  must  be  extremely  difficult.  In  many  cases  it  is  impos- 
sible, for  there  are  no  signs  which  can  be  regarded  as  positively 
conclusive.  The  trichomonas  vaginalis,  once  supposed  by  Donne 
to  be  pathognomonic  of  specific  vaginitis,  is  now  known  to  exist 
in  the  pus  of  that  which  is  simple ;  and  urethritis,  formerly  viewed 

'  This  view  is  denied  by  many  of  the  best  anthorities,  who  regard  pronorrhcea  as 
having  nothing  specific  about  its  nature.  At  the  same  time  that  I  have  no  wish 
to  ignore  the  opinion  with  which  mine  conflicts,  I  have  preferred  to  give  my  own 
impressions  without  discussing  the  matter. 


150  VAGINITIS. 

as  diagnostic  by  many,  is  sometimes  a  complication  of  the  simple 
form  and  is  sometimes  absent  in  the  specific. 

The  following  are  the  symptoms  which  should  lead  us  strongly 
to  suspect  the  specific  nature  of  a  case : 

Great  virulence  and  acuity  in  development ; 

Development  in  a  woman  previously  free  from  vaginal  dis- 
charges ; 

Marked  urethral  complication ; 

Copious  purulent  discharge ; 

Transmission  to  the  male  from  coition. 

Although  it  is  true  that  in  many  cases  these  symptoms  will 
render  us  certain  in  our  conclusions,  in  many  others  they  will 
exist  in  cases  certainly  of  non-specific  character.  I  have  on  two 
occasions  seen  them  all  attend  cases  of  vaginitis,  excited  by  acci- 
dental contact  of  chromic  acid  with  the  vaginal  walls. 

Course^  Duration^  and  Termination. — The  duration  of  the  disease 
will  depend  in  great  degree  upon  the  character  of  the  treatment 
adopted.  Under  proper  management  even  a  severe  case  may  often 
be  cured  in  from  two  to  three  weeks,  but  if  neglected,  it  may  con- 
tinue for  months  and  perhaps  years.  The  morbid  action  passing 
up  into  the  uterus  may  exist  as  an  endometritis  long  after  the 
vaginal  trouble  has  disappeared ;  or  it  may  pass  into  the  bladder 
and  excite  cystitis  ;  or  down  their  narrow  ducts  into  the  vulvo- 
vaginal glands. 

Dr.  JSToeggerath  has  lately  published  a  remarkable  paper  on 
"  Latent  Gonorrhoea  in  the  Female  Sex,"^  in  which  he  declares,  that 
certain  morbid  phenomena  in  the  female  organs,  which  have 
hitherto  been  considered  as  separate,  and  treated  independently, 
possess  a  common  basis  from  which  they  collectively  and  separately 
take  their  origin — this  being  nothing  more  nor  less  than  gonorrhoea. 
"  I  have,"  says  he,  "  undertaken  to  show  that  the  wife  of  every 
husband  who,  at  any  time  of  his  life  before  marriage,  has  con- 
tracted a  gonorrhoea,  with  very  few  exceptions,  is  aftected  wuth 
latent  gonorrhoea,  which  sooner  or  later  brings  its  existence  into 
view  through  some  one  of  the  forms  of  disease  about  to  be  de- 
scribed. ...  I  believe  I  do  not  go  too  far  when  I  assert  that 
of  every  100  wives  who  marry  husbands  who  have  previously  had 
gonorrhoea,  scarcely  10  remain  healthy ;  the  rest  suffer  from  it  or 
some  other  of  the  diseases  which  it  is  the  task  of  this  paper  to 
describe.    And,  of  the  ten  that  are  spared,  we  can  positively  affirm 


'  Die  Latente  Gonorrhoe  iin  Weiblichen  Geschlecht.     Bonn. 


SPECIFIC    VAGINITIS,    OR    GONORRHOEA.  157 

that  in  some  of  them,  through  some  accidental  cause,  the  hidden 
mischief  will  sooner  or  later  develop  itself." 

Tlie  diseases  to  which  this  author  refers  as  remote  consequences 
of  latent  gonorrhoea  are  perimetric  iniiammations,  both  acute  and 
chronic,  ovaritis,  and  catarrh  of  the  genital  tract.  These  when 
once  excited  are,  he  declares,  incurable,  and  render  the  life  of  the 
female  one  of  misery  and  danger.  These  women  rarely  become 
pregnant,  or,  if  they  do  so,  either  miscarry  or  bear  only  one  child. 
To  sustain  this  assertion  he  gives  the  statistics  of  81  cases,  of  which 
31  only  became  pregnant.  Of  the  31,  only  23  went  to  full  term; 
3  were  prematurely  delivered,  and  5  aborted.  Of  the  23  who  went 
to  full  term,  12  had  one  child  each  during  married  life  ;  7  had  two 
children  each  ;  3  had  three ;  1  had  four ;  and  among  the  23  Avomen 
there  were  five  abortions.  He  asserts  that  although  apparently 
cured,  gonorrhoea  may  exist  both  in  the  male  and  female  an  entire 
lifetime  in  a  latent  form,  which  may  at  any  moment  burst  forth 
into  acute  gonorrhoeal  inflammation,  or  excite  serious  uterine  or 
periuterine  inflammation. 

Extraordinary  as  these  views  may  at  first  sight  appear,  I  have 
given  them  at  length,  on  account  of  their  possible  importance  and 
the  respect  which  I  entertain  for  any  opinion  emanating  from  their 
author. 

Complications. — The  complications  of  gonorrhoea  in  the  female 
are  numerous  and  important.  Tlie  disorder  sometimes  becomes 
an  exceedingly  grave  one,  and,  in  some  instances,  destroys  life.  It 
may  induce  the  following  results: 

Buboes; 

Vulvar  abscesses; 

Cystitis ; 

Inflammation  of  vulvo-vaginal  glands; 

Endometritis ; 

Fallopian  salpingitis; 

Pelvic  peritonitis. 
Mr.  Salmon,^  who  first  drew  attention  to  inflammation  of  the 
vulvo-vaginal  glands  as  a  result  of  the  disease  which  we  are  con- 
sidering, declares  that  it  is  quite  common. 

The  passage  of  the  disordered  action  into  the  uterus,  through  the 
tubes,  and  into  the  peritoneum  is  the  most  dangerous  of  all  its  con- 
sequences, and  produces  great  risk  to  life  from  the  pelvic  peritoilTlis 
which  it  excites. 

'  Burastead  on  Venereal  Dis.,  p.  172. 


158  VAGINITIS. 

Granular  Vaginitis. 

Definition  and  Synonyms. — This  variety  of  vaginitis  was  first 
described  by  Eicord,  under  the  name  of  Psorolytrie.  In  1844, 
M.  Deville/  a  pupil  of  Ricord,  described  it  fully,  and  it  was  sub- 
sequently treated  of  by  Blatin,  Guerin,  and  others,  under  the  names 
of  papular,  glandular,  and  granular  vaginitis. 

Pathology. — By  these  writers  it  was  regarded  as  an  hypertroj^hy 
of  the  muciparous  follicles,  lying  embedded  between  the  rugse  of 
the  vagina.  This  hypertrophy,  it  was  thought,  was  generally  the 
result  of  pregnancy,  though  it  was  admitted  that  it  might  arise 
from  simple  or  specific  vaginitis.  Many  recent  writers  deny  the 
existence  of  this  variety  of  vaginitis,  and  view  it  only  as  an  hyper- 
trophy of  vaginal  papillfB,  the  result  of  the  forms  of  the  aftection 
already  mentioned.  Thus  Dr.  Bumstead,^  in  speaking  of  granula- 
tions found  in  the  vagina  as  a  result  of  vaginitis,  says,  "They  have 
been  erroneously  regarded  by  Dr.  Deville  as  peculiar  to  the 
vaginitis  of  pregnant  women."  Scanzoni^  and  West^  both  deny  its 
existence,  and  upon  the  same  ground,  viz.,  the  fact  that  Mandl  and 
Kolliker  have  discovered  very  few  mucous  follicles  in  the  vaginal 
mucous  membrane.  When,  however,  in  opposition  to  the  negative 
fact  that  these  excellent  observers,  supported  by  Robin  and  Sappey, 
have  not  discovered  these  glands,  is  arrayed  the  positive  fact  that 
Huschke,  Jamain,  Richet,  Becquerel,  Guerin,  and  others  hove  done 
so,  the  grounds  for  denial  must  be  admitted  to  be  insufficient. 
Even  if  such  evidence  of  the  propriety  of  admitting  this  variety  of 
vaginitis  did  not  exist,  clinical  research  would  corroborate  the 
truthfulness  of  the  deductions  of  M.  Deville. 

The  disease  is  characterized  by  hemispherical  granulations,  about 
as  large  as  half  a  millet-seed,  scattered  thickly  over  the  mucous 
membrane  of  the  vagina  and  over  the  cervix  uteri.  This  variety 
of  the  disease  appears  to  bear  the  same  relation  to  simple  vaginitis 
that  follicular  vulvitis  does  to  the  purulent  form  of  that  afiection. 
I  once  saw  a  case  of  granular  vaginitis,  so  striking  in  its  features 
that  the  attending  physician  had  expressed  to  the  patient's  family 
his  feare  that  malignant  disease  was  developing.  He  became  at 
once  convinced  of  his  grave  error,  when  shown  a  description  of  the 
disease  which  really  existed,  and  with  which  he  had  never  before 
met.    Although  I  believe  in  the  validity  of  this  variety  of  vaginitis, 

'  Archiv.  de  M^d..  4th  pories.  t.  v.  ^  Qp.  cit. 

3  Diseases  of  Females.  Am.  ed..  p.  529. 
*  Diseases  of  "Women,  Eng.  ed.,  p.  640. 


GRANULAR    VAGINITIS.  159 

I  must  declare  that  I  have  very  rarely  met  with  it  out  of  the  con- 
dition of  pregnancy. 

Causes. — The  glandular  hypertrophy  which  gives  to  the  disease 
its  characteristic  features  and  name,  generally  results  directly  from 
pregnancy,  though  it  may  be  produced  by  either  simple  or  specific 
vaginitis.     Some  women  suffer  from  it  in  successive  pregnancies. 

SymiJtoms.—li  demonstrates  its  presence  by  the  symptoms  already 
recorded  as  characteristic  of  simple  and  sijecific  vaginitis.  With 
these,  pruritus  vulvae  and  a  lichenous  eruption  about  the  pubes  are 
apt  to  appear.  As  parturition  comes  on  and  puts  an  end  to  preg- 
nancy, it  usually  disappears,  very  often  without  any  treatment 
whatever. 

Treatment  of  Vaginitis. — The  treatment  of  the  various  forms  of 
this  disease  is  so  similar  that  it  may  be  described  under  one  head, 
modifications  beino;  susffifested  for  those  cases  which  have  assumed 
a  sub-acute  or  chronic  aspect.  If  the  case  be  one  of  acute  character, 
the  patient  should  be  kept  perfectly  quiet  in  bed,  and  locomotion 
and  sexual  intercourse  strictly  interdicted.  Pain  should  be  relieved 
by  opiate  or  other  anodyne  suppositories  placed  in  the  rectum,  and 
febrile  action  prevented  or  combated  by  mild,  unstimulating  diet  and 
refrigerants.  Every  fifth  or  sixth  hour  the  patient,  placing  under 
the  buttocks  a  bed-pan,  upon  which  she  lies,  and  between  the  thighs 
a  vessel  of  warm  water  containing  boiled  starch,  infusion  of  linseed, 
bran,  or  poppies  to  render  it  soothing,  should,  by  means  of  a  syringe 
with  continuous  jet,  or  an  irrigator,  throw  a  steady  stream  against 
the  cervix  uteri  for  fifteen  or  twenty  minutes,  or  even  for  a  longer 
time.  The  methods  most  appropriate  for  syringing  the  vagina  are 
fully  described  in  chapter  fifteen,  and  to  it  the  reader  is  referred 
for  details. 

After  the  severity  of  the  attack  has  been  subdued  by  these 
means,  the  acetate  of  lead  or  sulphate  of  zinc,  with  tr.  of  opium, 
may  be  added  to  the  water  in  small  amounts,  not  more  than  a 
drachm  of  the  mineral  preparations  being  dissolved  in  a  gallon  of 
fluid.  As  soon  as  the  signs  of  acute  inflammation  have  disap- 
peared, the  sulphate  of  alum,  tannin,  or  infusion  of  oak  bark  may 
be  employed  to  render  the  fluid  injected  more  decidedlj-  astringent. 
At  the  same  time  laxatives  should  be  administered,  and  ardor  urinse 
relieved  by  the  use  of  soda,  potash,  or  other  alkaline  diuretics. 
Should  inflammatory  action  run  very  high  and  much  pain  be 
experienced,  great  benefit  will  be  derived  from  the  free  administra- 
tion of  opium,  which  should  be  given  until  complete  quiescence 
of  the  nervous  system  is  accomplished. 


150  VAGINITIS. 

When  the  acute  form  shows  a  tendency  to  become  sub-acute  or 
chronic,  tlie  speculum  of  Sims  should  be  cautiously  introduced, 
the  whole  vaginal  canal  painted  over  with  a  solution  of  nitrate  of 
silver,  one  drachm  of  the  salt  to  one  ounce  of  water,  and  a  tampon 
of  cotton  saturated  with  the  following  mixture,  introduced,  so  as 
to  till  the  vagina  without  too  much  distention: 

R. — GlyceriniE,  5iv. 
Acidi  tannici,  3^^- 
Morpliiae  sulphat.  gr.  ij. — M. 

Such  a  tampon,  or  one  saturated  with  glycerine  containing  sul- 
phate of  zinc  or  acetate  of  lead,  may  be  allowed  to  remain  for  tM'^o 
days  at  a  time. 

In  place  of  this,  after  free  vaginal  injection,  suppositories,  com- 
posed of  butter  of  cocoa  or  gelatine  and  gum  tragacanth,  with  per- 

Fig  41. 


Hard  rubber  tube  with  piston,  for  placing  medicated  cotton 
or  suppositories  in  the  vagina. 

sulphate  of  iron,  alum,  copper,  zinc,  or  oi)ium,  may,  by  means  of 
the  suppository  tul^e  represented  by  Fig.  41,  be  daily  placed  in  the 
upper  part  of  the  vagina. 

The  following  is  a  good  formula : 

R. — Acidi  tannici,  3j. 

Morphiae  sulphat.  gr.  iij. 
Butyr  cacao,  q.  s. 
M.  et  ft.  supposit.  No.  x. 

S.  One  per  vaginam  every  night  and  morning  after  use  of  the  syringe. 

In  some  cases,  where,  for  example,  the  vagina  is  very  narrow  or 
very  sensitive,  patients  will  object  to  the  size  of  the  vaginal  sup- 
pository tube.  For  them  the  small  rectal  suppository  tube  can  be 
made  to  answer.  The  apex  of  the  cone  of  the  suppository  is  fixed 
in  the  mouth  of  the  tube,  and  remains  there  with  suiRcient  tena- 
city to  admit  of  its  introduction  to  the  cervix. 

As  the  disease  passes  into  the  chronic  form,  the  general  state  of 
the  patient  should  be  carefully  watched,  and  if  tonic  or  chalybeate 
treatment  be  indicated,  it  should  at  once  be  resorted  to.  During 
the  treatment  of  this  affection  all  stimulants,  spices,  and  highly 
seasoned  food  should  be  avoided. 


ATBESIA    VAGINA.  161 


CHAPTER    VIII. 


ATRESIA  VAGINA. 


Definition  and  Synonyms. — The  term  atresia,  derived  from  a, 
privative,  and  rpaw,  "I  perforate,"  signifies  an  imperforate  condi- 
tion, and  should  in  its  strict  import  he  limited  to  complete  closure 
of  an  aperture  or  canal,  hut  custom  sanctions  its  application  to  any 
obliteration  or  occlusion  which  is  so  extreme  as  to  remove  the  case 
from  the  class  of  strictures. 

The  genital  canal  of  the  female  may  he  imperforate  at  the  vulva, 
in  tlie  vagina,  or  in  the  canal  of  the  uterus  itself.  In  the  present 
essay  it  is  proposed  to  treat  only  of  those  forms  which  affect  the 
vagina  and  receive  the  appellation  which  serves  as  the  caption  of 
this  chapter. 

History. — Hippocrates^  refers  to  this  condition  as  a  result  of 
labor ;  Aristotle  speaks  of  the  accidental  and  congenital  varieties ; 
Celsus  devotes  a  chapter  to  it,  and  it  claims  attention,  as  we  come 
down  to  subsequent  times,  from  Aetius,  Avicenna,  Lanfranc, 
Wierus,  Ruj^sch,  Mauriceau,  and  Roonhuysen.  Heister  and  Boyer 
advanced  our  knowledge  of  it,  but  it  was  left  for  the  daring  inves- 
tigations of  Amussat  and  Debron  to  place  its  cure  among  the 
achievements  of  modern  surgery. 

Pathology. — As  a  result  of  injury  from  mechanical,  chemical,  or 
pathological  agencies,  a  vagina  once  fully  developed  may  close  from 
adhesion  of  its  walls ;  its  calibre  may  be  diminished  by  absolute 
removal  of  its  component  structures  in  consequence  of  ulceration 
or  sloughing;  or  the  other  parts  of  the  female  genital  system  may 
go  on  to  full  development  while  this  is  arrested  in  its  growth  and 
remains  a  fibrous  cord  rather  than  a  distensible  canal. 

Varieties. — Atresia  may  be  either  congenital  or  accidental ;  and 
it  may  likewise  be  partial  or  complete.  In  a  case  of  stillicidium 
mensium,^  presenting  itself  at  the  clinique  for  diseases  of  women 
in  the  College  of  Physicians  and  Surgeons,  I  found  the  vagina 

'  Pviesch,  De  I'Atresie  des  Voies  Genitales  de  la  Femme.     Paris,  1864. 
2  This  term  is  employed  by  Aetius,  Tetrab.  iv,  p.  990. 
11 


152  ATRESIA    VAGINA. 

apparently  completely  closed  at  its  middle,  yet  permitting  a  slight 
flow  of  menstrual  blood.  Upon  careful  examination  a  small  open- 
ing, admitting  only  a  probe,  was  discovered,  leading  into  a  sac 
between  the  vaginal  constriction  and  the  neck  of  the  uterus,  which 
contained  several  ounces  of  thick,  tenacious  blood. 

If  the  atresia  be  congenital,  the  whole  canal  will  probably  be 
found  obliterated  ;  but  this  is  rare.  Generally  the  inferior,  middle, 
or  upper  part  is  the  seat  of  stricture. 

Causes. — The  following  causes  may  be  enumerated  as  produc- 
tive of  it : 

Arrest  of  development ; 

Prolonged  and  difficult  labor ; 

Chemical  agents  locally  applied ; 

Mechanical  agencies ; 

Sloughing,  the  result  of  impaired  vitality ; 

Syphilitic  or  other  extensive  ulcerations. 

One  case  which  has  come  under  my  observation  resulted  from 
syphilis;  another  from  prolonged  labor;  another  from  the  acci- 
dental passage  of  a  sharp  bit  of  wood  up  the  vagina ;  and  another 
from  retention  of  the  foetal  body  for  two  hours  after  delivery  of 
the  head.  Among  the  causes  of  sloughing  from  impaired  vital 
force  should  be  especially  mentioned  the  continued  and  eruptive 
fevers,  typhus  fever,  scarlatina,  variola,  etc.;  and  cholera  as  a  cause 
of  the  accident  is  referred  to  b}^  M.  Courty.^  Dr.  Trask,  of  Astoria, 
]!T.  Y.,  has  written  an  excellent  article  upon  this  subject,  his  con- 
clusions being  based  upon  thirty-six  cases,  of  which  fifteen  were 
due  to  prolonged  labor. 

8ym.ptoms. — The  disorder  will  demonstrate  its  existence  only  by 
incapacitating  the  vaginal  canal  for  its  important  functions,  copu- 
lation and  transmission  of  menstrual  blood.  Should  it  occur  in 
one  too  young  or  too  old  to  require  such  functions  from  the  vagina, 
no  suspicion  will  be  aroused  as  to  its  existence.  The  notice  of  the 
practitioner  will  generally  be  called  to  the  patient  by  amenorrhoea 
or  by  an  inability  to  perform  the  act  of  coition.  Should  the  men- 
strual hemorrhage  have  taken  place,  a  large  amount  of  blood  will 
generally  be  found  confined  above  the  constricted  part  of  the  canal, 
and  violent  uterine  contractions  will  have  demonstrated  the  eftbrts 
which  the  uterus  has  made  to  expel  the  accumulation.  Besides 
these,  no  other  rational  signs  will  show  themselves,  but  they  will 

>  Mai.  de  I'Uterus,  p.  369. 


PHYSICAL    SIGNS,    RESULTS,    ETC.  163 

be  sufficient  to  urge  upon  the  attendant  the  necessity  for  a  physical 
exploration. 

Physical  Signs. — The  patient  being  placed  upon  the  back,  and 
vaginal  touch  attempted,  entrance  of  the  finger  into  and  up  the 
vagina  will  be  found  to  be  impossible.  Investigation  will  prove 
that  this  is  not  due  to  vaginismus,  imperforate  hymen,  or  adhe- 
sion of  the  labia  majora,  and  rectal  touch  will  usually  discover  the 
vagina  running  up  the  pelvic  cavity  as  a  fibrous  cord. 

Results. — From  the  mere  obliteration  of  the  vao-ina  there  is  no 
immediate  or  direct  derangement.  But  in  certain  cases  where 
menstrual  blood  is  poured  out  by  the  vessels  of  the  uterine  mucous 
membrane,  and  is  accumulated  at  each  monthly  epoch  in  tlie  }<ortion 
of  the  canal  above  the  stricture,  or  in  the  uterus,  which  is  dilated 
by  its  retention,  rupture  of  this  organ  or  of  the  Fallo}»ian  tubes 
may  occur ;  reflux  tlirough  these  tubes  into  the  peritoneum  may 
take  place,  and  pelvic  hematocele  be  the  consequence;  or  the  reten- 
tion of  the  menstrual  flow  may  produce  all  those  nervous  and  cere- 
bral symptoms  so  characteristic  of  such  an  occurrence. 

Prognosis. — The  prognosis  of  these  cases,  as  regards  the  possibility 
of  removal  of  the  abnormal  state,  will  depend  upon  the  extent  and 
completeness  of  the  obliteration  and  destruction  of  tissue.  The 
smaller  the  amount  of  vaginal  tissue  found  by  rectal  touch  and 
examination  by  a  sound  in  the  bladder  to  exist,  and  the  more  com- 
plete and  extensive  the  adhesion  of  the  vaginal  walls,  the  more 
closely  will  the  case  resemble  one  of  entire  absence  of  the  vagina. 
The  prognosis  as  to  permanent  cure  will  greatly  dej^end  upon  the 
patient.  If  she  be  a  woman  of  good  sense  and  perseverance,  and 
keep  up  distention  by  the  vaginal  plug,  not  for  months,  but  for 
years,  the  result  is  often  a  very  good  and  permanent  one.  If,  on 
the  other  hand,  she  ignores  the  risk  attendant  upon  the  cessation 
of  its  use,  ultimate  contraction  will  almost  surely  occur.  During 
the  process  of  making  a  canal  between  the  bladder  and  rectum,  one 
of  these  viscera  is  very  apt  to  be  cut  into,  or  the  peritoneum  may 
be  opened  at  the  fornix  vagina.  If  a  depot  of  menstrual  blood  be 
reached  and  evacuated,  death  is  by  no  means  rare  from  septictemia, 
purulent  absorption,  or  a  septic  endometritis  which  ends  in  lym- 
phangitis, or  in  salpingitis  and  peritonitis. 

Differentiation. — Before  any  surgical  interference  is  estal^lished 
for  the  relief  of  atresia,  it  should  be  diiferentiated  from  imperforate 
hymen  and  absence  of  the  vagina.  The  latter  very  rarely,  if  ever 
(Scanzoni*  says  never),  exists  without  simultaneous  absence  of  the 

'  Diseases  of  Females,  Amer.  ed.,  p.  4T8. 


154  ATRESIA     VAGINA. 

uterus  and  rudimentary  development  of  some  of  the  external  organs 
of  generation.  If  an  obliterated  vagina  be  present,  it  may  gene- 
rally be  recognized  as  a  hard,  fibrous  cord,  by  one  finger  in  the 
rectum  and  a  sound  in  the  bladder.  Sometimes  a  short  cul-de-sac 
will  be  found  at  the  vulvar  extremity,  and  another  at  the  uterine, 
which  are  united  by  a  cord  of  fibrous  character. 

Should  deformity  of  the  external  genitals  exist,  the  uterus  not 
be  discoverable,  and  no  signs  of  distress  at  menstrual  epochs  show 
themselves,  it  may  be  concluded  that  the  case  is  one  of  absence 
of  the  vao;ina,  and  not  of  complete  atresia.  But,  thanks  to  the 
boldness  of  Amussat,  even  absence  of  the  vagina  does  not  preclude 
the  possibility  of  establishing  an  artificial  canal.  The  importance 
of  the  difierentiation  consists  in  the  fact  that  the  surgeon  should  in 
such  a  case  be  doubly  cautious  and  circumspect  in  his  efforts,  and 
guarded  in  his  prognosis.  It  may  at  first  thought  appear  that  in 
case  there  be  no  evidence  of  the  existence  of  uterus  or  ovaries,  and 
no  inconvenience  be  experienced  from  retention  of  menstrual  blood, 
it  would  not  become  necessary  to  resort  to  an  operation  to  render 
the  vagina  pervious.  But  so  great  is  the  unhappiness  often  result- 
ing from  incapacity  of  the  woman  for  the  sexual  act,  that  this 
becomes  a  reason  for  her  to  demand  the  resources  of  art,  and  a  valid 
ground  for  interference  on  the  part  of  the  surgeon. 

Treatmod. — The  sudden  evacuation  of  menstrual  blood,  which 
has  been  for  a  long  time  imprisoned  in  the  uterus  and  vagina,  is 
always  a  procedure  attended  by  danger.  Even  where  the  obstruc- 
tion has  been  only  an  obturator  hymen,  such  an  operation  has  been 
followed  by  peritonitis  and  death.  The  chief  danger  is  probably 
dependent  upon  the  fact  that  the  imprisoned  fluid  distends  the 
uterus  and  Fallopian  tubes,  and  renders  them  so  sensitive  that  the 
admission  of  air  produces  a  septic  endometritis,  which  in  its  course 
and  termination  resembles  closely  the  most  common  form  of  puer- 
pjeral  fever.  I  have  seen  two  cases  end  fatally,  one  in  my  own  prac- 
tice, and  one  in  that  of  Dr.  Charles  S.  "Ward.  In  both,  septicaemia 
appeared  to  develop  itself,  probably  from  lymphangitis;  and  in  one, 
secondary  peritonitis  occurred.  This  is,  however,  only  a  supposi- 
tion, l)ased  upon  eases  proved  by  necropsy  to  be  of  this  character. 
In  neither  of  these  eases  was  an  autopsy  obtained. 

For  these  reasons,  such  accumulations  should  not  be  evacuated 
without  great  caution ;  and  it  is  always  well  for  the  operator  to 
announce  to  the  patient's  friends,  the  fact  that  dangerous  conse- 
quences may  result. 


RETAINED     MENSTRUAL    BLOOD.  165 

Methods  for  Evacuating  Retained  Menstrual  Blood. — Accumula- 
tions of  menstrual  blood  may  be  evacuated  by  two  metliods :  aspi- 
ration, and  puncture  by  a  small  trocar  from  which  air  is  excluded. 

The  great  advantage  of  the  former  plan  in  tliese  cases  is,  that  it 
enables  the  operator  to  reach  the  fluid  through  the  vagina,  the 
rectum,  or  the  abdominal  walls,  as  happens  to  be  most  convenient ; 
and  this  without  the  admission  of  air,  which  would  act  as  a  direct 
poison  upon  the  abnormal  mucous  surfaces.  It  is  safer  to  remove 
the  fluid  very  gradually,  and  not  at  one  time.  Once  in  ever^^  three 
or  four  days  a  portion  may  be  drawn  off  by  aspiration,  until  the 
cavity  is  emptied.  Let  it  be  remembered  that  there  is  no  steady 
increase  in  the  amount  of  fluid,  but  that  it  is  suddenly  and  greatly 
added  to  at  menstrual  epochs. 

In  some  cases,  rupture  of  the  tubes  has  occurred  after  the  uterine 
accumulation  has  been  evacuated.  In  these  cases  a  tubal  accu- 
mulation, due  to  menstrual  flow  from  the  salpingian  mucous  mem- 
brane, has  become  encysted  by  stricture  of  the  tube.  The  sudden 
emptying  of  the  uterus  causes  contraction  of  the  walls  of  the  tube, 
and  emptying  of  the  tubal  contents  into  the  peritoneum  is  the 
consequence.  This  danger  is  diminished  by  gradual  evacuation  of 
the  mass  of  blood  in  the  uterus. 

In  this  way  having  very  gradually  drawn  oft"  all  the  blood  which 
will  flow,  the  action  of  the  aspirator  should  be  reversed,  and  the 
emptied  cavity  thoroughly  and  repeatedly  washed  out  with  warm 
carbolized  water.  Then  the  patient  should  be  kept  perfectly  quiet, 
in  the  horizontal  posture,  and  under  the  gentle  influence  of  opium 
and  quinine  for  four  or  five  days. 

By  careful  observation  in  these  cases  the  menstrual  epoch  can 
usually  be  ascertained.  If  it  be  known,  this  treatment  should  be 
instituted  four  or  five  daj^s  after  its  passage,  and  kept  up  for  about 
ten  days.  Then  an  effort  may  be  made  to  remove  the  obstruction 
which  has  produced  the  evil. 

It  may  be  asked  what  should  be  done  in  case  an  aspirator  is  not 
attainable.  Should  the  distention  of  the  uterus  be  so  great  as  to 
render  delay  dangerous,  or  travelling  on  the  part  of  the  patient 
unadvisable,  it  may  be  replaced  by  a  very  small  trocar,  attached  to 
which  is  a  gutta-percha  tube,  which  is  connected  with  a  David- 
son's syringe,  or  other  exhauster.  The  trocar  and  canula  may  be 
plunged  through  the  obturator  tissue  or  the  wall  of  the  rectum, 
and  the  fluid  evacuated. 

Bernutz,^  who  believed  that  the  admission  of  air  into  a  uterus 


■  Clin.  JMed.  sur  les  Mai.  dcs  Fein;nes,  vol.  i,  p.  303. 


166  ATRESIA    VAGINA. 

previously  closed  to  its  entrance,  causes  contraction,  which  forces 
imprisoned  blood  into  the  peritoneum,  advised  for  the  avoidance 
of  this  accident  the  following  plan.  He  proposed  to  operate  in 
from  eio-lit  to  ten  days  after  menstruation,  when  the  calm  which 
succeeds  it  is  well  established,  and  at  the  same  time  at  a  period 
distant  from  the  next  epoch.  He  practised  puncture  by  a  very 
small  trocar  guarded  by  gold-beater's  skin.  In  this  way  gradual 
discharge  is  accomplished,  and  air  excluded.  He  did  not  leave 
the  trocar  in  place,  but  prefered  subsequent  puncture,  if  necessary. 
The  fatal  termination  of  four  cases  led  him  to  the  adoption  of  these 
precautions. 

After  evacuation  of  all  the  retained  blood,  and  diminution  of 
the  size  of  the  distended  uterus,  he  recommended  the  practice  "  to 
make  sure  of  the  permanent  freedom  of  the  excreting  channel  by 
as  extensive  incision  of  the  obturator  membrane  as  is  practicable, 
and  the  employment  of  dilatation." 

Of  these  plans  for  evacuating  retained  menstrual  blood,  aspira- 
tion is  the  safest,  simplest,  and  least  painful. 

With  the  array  of  fatal  cases  now  on  record  from  sudden  evacu- 
ation by  means  which  admit  air  to  the  cavity,  and  with  the  means 
at  our  disposal  for  greatly  diminishing  these  dangers  ;  where  there 
is  no  necessity  for  haste  (and  ordinarily  there  is  none),  it  becomes  a 
question  which  each  must  answer  for  himself,  whether  in  these 
days  of  telegraphs,  railroads,  and  profusion  of  medical  charities,  it 
is  not  absolutely  culpable  in  any  operator  to  ignore  the  existing 
facts,  and  to  expose  his  patient  to  a  risk  which  science  enables  him, 
at  least,  greatly  to  lessen. 

Operation  for  Rendering  the  Obliterated  Vagina  Pervious. — Before 
operation,  if  there  be  any  doubt  as  to  the  presence  of  the  uterus  or 
as  to  its  size  or  position,  the  hand  may  be  introduced  into  the 
rectum,  after  stretching  the  sphincter,  and  a  full  and  satisfactory 
exploration  made. 

If  on  account  of  great  obesity  it  be  found  impossible  to  appre- 
ciate the  extent  of  tissue  existing  between  the  bladder  and  rectum, 
and  consequently  in  the  course  in  which  the  vagina  is  to  be  opened, 
or  perhaps  absolutely  constructed,  the  urethra  may  be  rapidly  dis- 
tended by  sounds  so  as  to  admit  the  finger  to  the  bladder.  Then 
the  index  and  middle  fingers  of  the  right  hand  being  carried  up 
the  rectum,  and  the  index  of  the  left  introduced  into  the  bladder 
this  important  point  may  be  ascertained. 

Before  operating,  the  patient  should  be  an?esthetized,  and  the 
bladder  and  rectum  emptied  of  their  contents.      She  should  be 


REXDERING    THE     OBLITERATED    VAGINA    PERVIOUS.       167 

placed  in  the  lithotomy  position,  upon  a  strong  table,  before  a 
window  giving  a  good  light. 

The  labia  being  retracted  by  the  fingers  of  two  assistants,  hold- 
ing the  thighs,  the  finger  of  a  third,  who  kneels  by  the  side  of  the 
operator,  is  introduced  into  the  rectum.  A  steel  sound  is  then 
passed  into  the  bladder,  which  the  assistant,  on  the  left  of  the 
woman,  holds  in  the  right  hand.  At  this  moment,  this  assistant 
holds  the  w^oman's  knee  under  his  left  arm,  retracts  the  labium 
by  his  left  hand,  and  holds  the  sound  in  his  right  hand.  The 
sound,  he  must  press  upon  gently,  so  as  to  let  the  operator's  finger 
recognize  its  presence  as  it  works  its  way  up  the  vagina.  By  means 
of  a  pair  of  curved  scissors,  conducted  up  to  the  point  of  obliteration 
upon  one  finger,  the  tissue  between  the  urethra  and  rectum  should 
then  be  very  cautiously  cut,  in  a  transverse  direction,  and  the  finger 
introduced  into  the  opening  made.  This  is  really  almost  all  the  cut- 
ting which  should  be  done ;  the  rest  should  be  accomplished  chiefly 
by  the  finger.  This,  by  the  sense  of  touch,  tells  the  operator  exactly 
how  nearly  he  approaches  the  sound  in  the  bladder  on  one  Side, 
and  the  finger  in  the  rectum  on  the  other.  To  one  who  lias  not 
tried  this  plan,  the  facility  with  which  the  adherent  vaginal  walls 
may  be  separated,  or  a  new  tract  torn  through  the  tissues,  will  be 
surprising.  Now  and  then,  the  application  of  the  scissors  or  of  a 
curved,  probe-pointed  bistoury  will  become  necessary,  but  every 
such  necessity  constitutes  an  element  of  danger. 

As  the  o}  erator  approaches  the  regions  around  the  cervix,  he 
may  become  bewildered  as  to  its  position.  Under  these  (;ircum- 
stances,  let  him  make  pressure  l)y  his  unoccupied  hand,  over  the 
hypogastrium,  so  as  to  force  the  hard  cervix  down  upon  his  finger. 
Should  he  still  feel  a  sense  of  bewilderment,  he  should  pass  the 
four  fingers  of  the  right  hand,  and  the  hand  itself  except  the 
thumb,  into  the  rectum,  seize  the  uterus,  steady  it,  and  press  its 
cervix  down  upon  the  finger  in  the  vagina.  Should  he  not  succeed, 
even  now,  in  determining  the  relation  of  parts,  he  should  stop  the 
operation,  introduce  a  vaginal  plug,  and  finish  it  in  a  week  or 
ten  days.  Ordinarily,  if  he  proceed  in  the  cautious  manner  de- 
scribed, after  having  beforehand  carefully  explored  the  pelvis,  and 
the  uterus  exist,  he  will  succeed  in  reaching  it. 

This  method  of  operating  is  that  which  is  said  to  have  been 
adopted  by  Amussat  in  1832,  and  by  Dupuytren.  Dr.  Emmet, 
wdiose  experience  in  this  class  of  cases  has  been  extensive,  declares 
that  if  the  new  tract  be  created  by  incisions  by  scissors  and  tearing 
of  tissue  ])y  the  fingers,  subsequent  contraction  and  atresia  are  less 


163  ATRESIA     VAGINA. 

likely  to  occur  tlian  if  a  knife  be  used.  According  to  liis  experi- 
ence, incisions  made  by  the  knife  granulate  and  undergo  cicatricial 
contraction  with  much  greater  rapidity. 

However  the  operation  for  atresia  be  performed,  there  is  always 
great  danger  of  relapse,  and  unless  special  means  be  adopted  for 
maintaining  the  perviousness  of  the  canal,  it  will  invariably  occur. 
To  prevent  such  a  result,  a  plug  of  glass,  such  as  represented  by 
Fig.  38,  should  be  introduced  into  the  vagina,  secured  by  a  T  band- 
age, and  worn  for  weeks.  After  this  it  should  be  kept  in  place  at 
night  for  many  months  and,  if  necessary,  for  years.  Where  the 
entire  canal  has  been  obliterated,  even  these  efforts  may  fail  and 
contraction  occur  above,  which  gradually  advances  to  the  ostium 
vaginoe. 

If  menstrual  blood  have  been  imprisoned  above  the  strictured 
portion  of  the  vagina,  the  canal  should,  for  a  fortnight  after  ope- 
ration, be  kept  scrupulously  clean  by  injections  of  tepid  water 
practised  twice  a  day.  If  the  uterus  and  tubes  have  been  dis- 
tended by  retained  fluid,  the  cavity  of  the  former  should,  just 
after  the  operation,  be  carefully  washed  out  with  tepid  water 
very  slightly  impregnated  with  carbolic  acid,  tincture  of  iodine, 
or  Labarraque's  solution  of  soda.  The  patient  should  then  be  kept 
as  quiet  as  possible  in  the  recumbent  posture,  and  slightly  under 
the  influence  of  opium. 

The  period  at  which  operation  should  be  resorted  to  for  con- 
genital atresia  is  a  subject  of  importance.  Velpeau  advocates 
operating  in  infancy,  but  Puesch,  Boycr,  and  others  regard  the  age 
of  puberty  and  approach  of  menstruation  as  a  more  appropriate 
time.  Should  the  menopause  have  arrived,  no  operation  will  be 
called  for. 

It  should  not  be  forgotten  that  delay  in  interference  is  often 
very  disastrous  during  the  period  of  menstrual  activity,  for  lives 
have,  in  numerous  instances,  been  destroyed  by  rupture  of  the 
Fallopian  tubes,  and  even  of  the  uterus  itself,  as  seen  by  Puesch. 
This  observer  drew  liis  conclusions  from  258  cases  of  atresia,  in 
18  of  which  rupture  of  the  Fallopian  tubes  from  distention  by 
menstrual  blood  occurred.  In  one  instance  of  atresia  I  saw  an 
hematocele  the  size  of  an  infant's  head,  result  from  regurgitation 
of  blood  through  the  tubes  into  the  peritoneal  cavity.  It  is  highly 
probable  that  the  mental  emotion  of  the  patient,  and  her  struggles 
during  the  operation,  may  account  for  the  entrance  of  blood  into 
the  peritoneum  as  noted  by  Bernutz.  Hence,  every  effort  sliould 
be  made  to  avoid  these,  and  care  should  be  taken  not  to  allow  of 


PROLAPSUS    VAGIN'^.  169 

pressure  upon  the  uterus  in  examination,  or  in  restraining  the 
patient. 

In  an  interesting  report  of  a  case  of  atresia  operated  upon  by  Dr. 
Grange  Simons,  of  Charleston,  in  the  Transactions  of  the  South 
Carolina  Medical  Association,  1872,  an  opening  was  made  through 
the  fornix  vaginse,  and  the  uterus  not  being  found,  the  operation 
was  abandoned.  The  patient  menstruated  through  this  opening 
afterwards.  8ubse(iuently  she  died  of  tetanus,  and  the  vaginal 
opening  was  found  to  communicate  with  a  Fallopian  tube  which 
was  there  adherent  to  the  vagina. 


CHAPTER    IX. 

PROLAPSUS  VAGINA  AND  VAGINAL  HERNIA. 

Prolapsus  Vaginae. 

It  might  upon  very  valid  grounds  be  maintained  that  prolapsus 
vaginae,  recti,  and  vesicae  are  so  intimately  connected  with  prolapsus 
uteri,  that  this  chapter  should  have  been  united  with  that  upon 
the  latter  condition.  I  have  especially  avoided  this  course,  for 
the  reason  that  I  wish  to  direct  the  reader's  attention  particu- 
larly to  prolapse  of  the  vagina  as  a  primary  condition,  one  often 
long  existing  without  uterine  descent,  and  very  frequently  pre- 
ceding that  state  as  a  causative  influence.  For  any  repetition 
which  may  occur  in  the  two  chapters,  I  offer  no  apology,  in  view 
of  the  great  importance  of  both  subjects. 

Definition  and  Synonyms. — The  mechanism  by  which  the  pelvic 
organs  of  the  female  are  kept  in  their  proper  positions,  and  rela- 
tions to  each  other,  offers,  in  its  simplicity  and  perfection,  an 
excellent  example  of  that  adaptation  of  means  to  an  end  which  is 
so  often  repeated  in  the  animal  economy.  The  uterus  is  so  sus- 
tained that  when  necessity  requires  it,  not  only  in  pregnancy  but 
under  a  number  of  other  circumstances,  it  may  rise  or  fall,  or  tilt 
backwards  or  forwards,  while  the  rectum,  Ijladder,  and  lowest 
layer  of  small  intestines  are  kept  in  place  and  allowed  to  distend 
and  empty  themselves  without  material  change  of  relation. 

The  organs  which  are  mainly  instrumental  in  this  result  are  the 


170  PROLAPSUS    VAGlNuE. 

va2:ina,  tlie  peritoneum,  the  uterine  ligaments,  and  the  pelvic 
areolar  tissue.  The  first  of  these  performs  an  important  part.  By 
it  the  uterus  and  super-imposed  layer  of  small  intestines  are  to  a 
great  extent  supported,  the  bladder  is  prevented  from  falling  back- 
wards when  in  a  state  of  repletion,  and  the  anterior  wall  of  the 
rectum  from  undergoing  displacement  forwards.  Dr.  Savage'  has 
said,  "  the  vagina  does  not  support  the  uterus  under  any  circum- 
stances." It  is  difficult  to  concur  in  this  statement  when  in  prac- 
tice we  see  a  prolapsed  uterus,  vagina,  and  bladder  perfectly  sus- 
tained by  astringents  applied  to  the  vaginal  walls,  by  operations 
narrowing  that  canal,  and  by  simply  giving  support  to  its  walls, 
posteriorly,  by  restoration  of  the  perineum. 

,When  the  tone  of  the  walls  of  the  vagina  is  impaired  and  they 
pouch  into  its  own  canal  so  as  to  fall  downwards  towards  the 
vulva,  the  condition  is  called  prolapsus.  As,  however,  loss  of  the 
support  which  the  vagina  previously  gave  usually  results  in  descent 
of  the  uterus,  small  intestines,  bladder,  and  anterior  wall  of  the 
rectum,  it  is  often  included  under  the  names  of  prolapsus  uteri, 
cystocele,  enterocele,  or  rectocele.  As  considerable  diversity  of 
opinion  exists  concerning  the  nature  of  prolapsus  vaginae,  it  is 
necessary  for  us,  before  j^roceeding,  to  comprehend  its  definition 
with  perfect  clearness.  By  some  it  is  maintained  that  hernia  of 
neighboring  viscera  into  the  vagina  should  not  be  included  under 
the  head  of  prolapsus,  which,  as  Colombat  declares,  is  an  "  inver- 
sion of  the  internal  lining  nieml>rane,  caused  by  infiltration  of 
the  cellular  texture  that  unites  the  mucous  to  the  subjacent  mem- 
branes." By  others  it  is  believed  that  true  prolapse  is  impossible 
without  simultaneous  displacement  of  one  or  more  of  the  surround- 
ing pelvic  organs.  All  admit,  of  course,  that  in  such  an  exuberant 
development  or  hypertrophy  as  that  which  occurs  during  preg- 
nancy, a  portion  of  the  canal  may  be  forced  out  of  the  vulva,  but 
this  is  not  what  is  ordinarily  meant  by  the  term  prolapsus  vaginae. 
Dr.  Savage^  expresses  himself  thus  upon  the  point :  "  Prolapse  of 
the  vagina  alone,  or  prolapse  of  the  vaginal  mucous  membrane 
alone,  are  two  afiiections  which,  anatomically  considered,  would 
seem  impossible." 

It  is  an  important  question  whether  there  can  be  prolapse  of  the 
vagina  without  rectocele,  cystocele,  or  uterine  prolaf)se.  The  ante- 
rior or  upper  wall  of  the  vagina  is  closely  bound  to  the  base  of  the 
bladder  and  the  front  of  the  cervix  uteri,  and  by  means  of  the 


'  Lancet,  Feb.  1858.  2  Female  Pelvic  Organs. 


PATHOLOGY.  171 

utero-sacral  ligaments  it  is  indirectly  attached  to  the  sacrum.  This 
wall  aids  in  support  of  the  uterus,  bladder,  and  small  intestines. 
The  posterior  wall  is  not  so  firmly  bound  to  the  rectum,  though 
the  adhesion  at  the  extremity  of  the  utero-rectal  pouch  of  perito- 
neum is  quite  strong.  At  the  perineal  septum,  a  point  a  short 
distance  above  the  vulva,  and  just  at  the  upper  edge  of  the  perineal 
body,  the  muscular  walls  of  the  vagina  pass  off  to  attach  them- 
selves to  the  ischio-pubic  rami.  At  that  point  the  canal  is  con- 
stricted by  the  pubo-coccygeus,  the  true  sphincter  vaginpe  muscle. 
The  mucous  membrane  of  the  canal  passes  down  to  the  fourchette. 
These  anatomical  arrangements  account  for  the  fact  that  prolapse 
of  the  vagina  without  simultaneous  displacement  of  one  or  more 
of  its  surrounding  viscera  is  exceedingly  rare,  and  that  when  it 
does  occur  as  a  distinct  disease  it  is  very  generally  found  to  affect 
only  the  posterior  wall.  I  have  met  with  no  case  in  which  the 
anterior  wall  has  decidedly  prolapsed  without  coincident  descent 
of  the  bladder,  but  I  have  seen  repeated  instances  of  prolapse  of 
the  posterior  wall  without  alteration  of  the  position  of  the  rectum. 

Pathology. — Any  influence  which  impairs  the  natural  tonicity 
and  strength  of  the  vaginal  canal,  rendering  it  abnormally  volumi- 
nous and  lax,  or  which  destroys  its  lower  buttress  or  support,  will 
tend  to  induce  this  affection.  As  pregnancy  and  parturition  com- 
bine most,  and  often  all,  of  these,  they  very  generally  furnish 
both  predisposing  and  exciting  causes.  The  development  of  the 
vagina,  and  increased  weight  of  the  uterus  dependent  upon  the 
former,  and  the  distention  of  the  canal  and  enfeebling  of  the 
sphincter  muscle  incident  to  the  latter,  all  unite  in  favoring  pro- 
lapsus. As  the  fibre  cells,  which  constitute  the  nascent  state  of 
the  uterine  muscular  fibres,  develop,  so  as  to  make  of  the  insig- 
nificant non-pregnant  uterus  the  powerful  organ  which  expels  the 
child  at  full  term,  so  do  those  of  the  vagina,  the  Fallopian  tubes, 
and  the  uterine  ligaments.  By  the  process  of  involution  which 
diminishes  the  size  and  weight  of  the  uterus,  these  parts  likewise 
return  to  their  original  dimensions.  Those  influences  which  arrest 
this  important  process  in  the  uterus,  resulting  in  subinvolution, 
likewise  affect  it  in  the  other  parts  mentioned,  and  render  them 
atonic  and  feeble. 

Prolapsus  vaginoe  is  very  rare,  except  in  those  who  have  borne 
children,  although  it  may  occur.  Sir  Astley  Cooper  met  with  it 
in  a  girl,  aged  seventeen,  who  was  admitted  into  Guy's  Hospital, 
for  supposed  prolapsus  uteri,  and  Prof.  Meigs^  mentions  that  Dr. 


'  Meiirs's  Translation  of  Colombat. 


l'J2  PROLAPSUS    VAGINA. 

Mutter,  of  Philadelpliia,  saw  it  occur  in  a  child  six  months  old  in 
consequence  of  a  convulsion. 

Causes.— From  what  has  just  been  said  the  following  causes  will 
naturally  suggest  themselves  as  those  most  likely  to  produce  this 
displacement : 

Violent  efforts  of  the  abdominal  muscles; 

Repeated  parturition; 

Senile  atrophy  of  vaginal  walls ; 

Rupture  of  perineum; 

Previous  distention  by  tumors; 

Long  continued  vaginitis; 

Subinvolution  of  the  vagina. 

Of  all  these  causes  subinvolution  of  the  vagina  is  the  most  fre- 
quent, more  especially  when  it  accompanies,  as  it  often  does,  rupture 
of  the  perineum,  Next  in  frequency  stands  senile  atrophy  and 
absorption  of  surrounding  adipose  tissue. 

It  is  evident  that  all  act  either  by  debilitating  the  power  of  the 
vaginal  walls  by  mere  mechanical  distention,  by  specifically  robbing 
them  of  their  tonicity,  or  by  removing  the  buttress,  against  which 
the  canal  rests  at  the  vulva. 

Varieties. — The  displacement  may  be  of  two  forms,  acute  and 
chronic.  The  power  of  the  canal  may  be  overcome  by  a  violent 
effort,  a  fit  of  coughing,  uterine  or  abdominal  contractions,  or 
similar  acts,  which,  with  great  suddenness,  force  the  contents  of 
the  abdomen  down  upon  the  pelvic  viscera.  This  occurrence,  which 
is  very  rare,  is  generally  accompanied  by  sudden  descent  of  the 
uterus,  or  occurs  soon  after  parturition.  The  ordinary  form  of  the 
affection  is  that  in  which  by  the  slow  and  steady  action  of  one  or 
more  of  the  causes  enumerated,  the  resistance  of  the  vagina  is 
gradually  overcome,  and  little  by  little  a  fold  is  forced  downwards 
towards  and  through  the  vulva.  The  first  variety  is  the  result  of 
a  few  minutes'  effort;  the  second,  that  of  months,  or  even  years 
of  morbid  action.  Prolapse  of  one  wall,  partial  prolapsus,  as  it 
has  been  styled,  is  often  lost  sight  of  in  view  of  the  hernia  of  the 
bladder,  rectum,  or  small  intestines,  which  accompanies  it.  Hence 
cystocele,  rectocele,  and  enterocele  may  be  regarded  also  as  com- 
plications of  the  affection. 

Course.,  Duration,  and  Termination. — A  sudden  attack  of  pro- 
lapsus being  overcome  by  proper  means,  and  the  patient  kept 
quiet,  may  disappear,  and  not  return ;  but  in  that  variety  which 
occurs  gradually  there  is  no  limit  to  the  duration  of  the  disease. 


CYSTOCELE.  173 

Generally,  the  physician  is  not  called  until  it  has  existed  for  a 
long  time  and  become  chronic.  The  most  important  results  of  the 
condition  are  prolapse  of  the  uterus,  bladder,  and  rectum,  one  or 
more  of  which  are  almost  sure  to  ensue. 

Prognosis. — The  prognosis  as  to  cure  will  depend  upon  the  degree 
and  duration  of  the  malady.  It  is  always,  whatever  be  its  extent, 
rolievable  by  surgical  means,  but  generally  proves  incurable  by 
those  of  medical  character. 

Symptoms. — Should  displacement  of  the  vagina  exist  alone,  that 
is,  without  creating  hernia  of  surrounding  organs,  the  patient  will 
complain  of  a  sense  of  discomfort  in  the  vagina,  with  a  tendency 
to  bearing  down,  as  if  to  expel  some  foreign  body ;  a  feeling  of 
heat,  fulness,  and  throbbing  at  the  vulva ;  a  certain  amount  of 
pelvic  uneasiness  in  walking,  or  making  any  muscular  effort,  and 
a  tendency  to  become  fatigued,  if  the  condition  be  one  of  aggra- 
vated character.  Physical  exploration  will  reveal  the  presence 
of  a  tumor  between  the  labia,  which  touch  will  demonstrate  to 
contain  no  liquid,  and  yet  not  to  be  solid  in  its  nature.  Some- 
times the  mucous  membrane  covering  it  is  excoriated,  ulcerated, 
and  purple  in  color ;  at  others  it  will  be  smooth,  shining,  tough, 
and  covered  by  pavement  epithelium.  A  simple  vaginal  prolapse 
of  any  extent  is,  as  has  been  stated,  quite  rare.  "VYlien  it  does 
<^ccur  it  generally  aifects  the  posterior  wall,  but  prolapse,  accom- 
})anied  by  hernia,  is  more  commonly  found  to  affect  the  anterior 
wall,  cystocele  existing.  Should  the  case  be  complicated  hy  vesical 
or  rectal  prolapse,  the  symptoms  just  enumerated  will  present 
themselves  with  the  addition  of  others  dependent  upon  disturb- 
ance of  the  functions  of  the  ^^art  which  forms  the  hernia.  In  one 
case  the  prominent  symptoms  will  point  to  the  bladder;  in  an- 
other, to  the  rectum,  and,  in  very  rare  instances,  to  the  small 
intestines. 

As  the  treatment  of  prolapsus  vaginae  is,  with  slight  modifica- 
tions, the  same  for  uncomplicated  and  complicated  cases,  it  will  be 
considered  after  the  subject  of  vaginal  hernise  has  been  discussed. 

Vaginal  Herniae. 

Cystocele. 

Cystocele,  or  vesico-vaginal  hernia,  consists  of  descent  of  the 
bladder  towards  the  vulva,  so  as  to  impinge  upon  the  vaginal 
canal.  When  the  anterior  wall  of  the  vao-ina,  which  is  closelv 
adherent  to  the  bladder,  the  base  of  which  it  in  part  sustains, 


174  PROLAPSUS    VAGINA. 

ceases  to  afford  tlie  required  resistance,  the  bladder,  partly  under 
this  influence  and  partly  under  that  of  traction,  descends  and 
forms  a  small  pouch  in  the  vagina.  This  is  at  first  very  small,  but 
gradually  it  increases,  until  at  last  it  forms  a  decided  tumor,  which 
protrudes  between  the  labia  majora.  The  pouch  thus  created 
becomes  filled  with  urine,  which,  in  the  ordinary  act  of  micturition, 
cannot  be  evacuated,  from  its  being  contained  in  a  species  of  diver- 
ticulum. This  undergoes  decomposition,  free  ammonia  is  formed, 
and  cystitis  or  vesical  catarrh  is  established,  which  annoys  the 
patient  by  pain,  heat,  vesical  tenesmus,  and  scalding  in  urination. 
Should  any  doubt  exist  as  to  the  character  of  the  tumor  felt  in  the 
vagina,  a  curved  sound  or  catheter  may  be  passed  into  it  through 
the  urethra  for  the  settlement  of  the  question. 

It  is  an  interesting  question  whether  cystocele  is  ever  the  cause 
instead  of  the  result  of  prolapse  of  the  vagina.  It  is  probable  that 
it  may  be  so  in  very  rare  cases,  though  such  a  connection  between 
the  two  affections  must  be  uncommon,  since  the  former  seldom 
occurs  except  in  women  who  have  borne  children,  and  thus  been 
exposed  to  influences  which  tend  to  diminish  vaginal  resistance. 
Scanzoni'  is  convinced  that  the  vesical  prolapse  is  sometimes 
primary,  and  due  to  irregular  spasmodic  contraction  of  the  fibres  of 
the  body  of  the  bladder  while  the  neck  remains  firm.  This  forces 
the  urine  to  the  fundus,  which  dilates  and  undergoes  displacement. 

Redocele. 

Rectocele,  or  recto-vaginal  hernia,  occurs  in  a  manner  similar 
to  that  by  which  the  bladder  descends.  The  j^osterior  wall  of  the 
vagina  not  only  ceasing  to  give  proper  sup[)ort  to  the  anterior  wall 
of  the  rectum,  but  dragging  it  obliquel}^  downwards,  this  forms  a 
pouch  which  soon  fills  with  fecal  matters.  The  feces,  becoming 
hard,  and,  in  consequence,  irritating,  create  mucous  inflammation 
and  discharge,  with  tenesmus,  obstinate  constipation,  and  hemor- 
rhoids. The  tumor  thus  formed  will  sometimes  equal  in  size  a 
man's  fist,  and  protruding  over  the  perineum  give  some  difiiculty 
in  diagnosis  from  its  size  and  solidity.  This  difiiculty  will  at  once 
disappear  uyjon  rectal  exploration  and  the  use  of  an  enema  of  ox  gall 
and  warm  water.  In  one  instance  I  saw  a  patient  confined  to  bed 
for  three  or  four  months  from  one  of  these  sacculated  accumulations 
of  feces,  under  the  supposition  that  cellulitis  existed,  which  by 
effused  lymph  had  completely  blocked  up  the  pelvis.     It  may  be 

'  Op.  cit.,  p.  497. 


ENTEROCELE.  175 

supposed  that  such  an  error  will  rarely  be  met  with,  yet  the  case 
which  I  have  just  mentioned  occurred  to  a  practitioner  of  great 
experience  and  ability. 

Enterocele. 

Enterocele,  or  entero-vaginal  hernia,  consists  in  descent  of  a 
portion  of  the  small  intestines  into  the  pelvis,  so  as  to  encroach 
upon  the  vaginal  canal.  Such  a  descent  usually  occurs  in  this 
manner:  a  loop  of  intestine  resting  in  Douglas's  cul-de-sac  stretches 
this  serous  prolongation,  and,  advancing  between  the  rectum  and 
vagina,  pushes  the  posterior  wall  of  the  latter  before  it  so  as  to 
form  a  tumor  at  the  vulva.  In  a  similar  manner  it  is  stated  that 
the  intestine  may  advance  between  the  bladder  and  uterus  and 
depress  the  anterior  vaginal  wall,  but  this  must  be  rare,  as  authors 
of  extensive  experience  assert  that  they  have  never  met  with  it. 

Enterocele  is  not  an  accident  likely  to  produce  evil  results  unless 
it  occur  during  labor,  when  strangulation  may  take  place.  Even 
at  this  time  such  a  complication  is  very  rare,  for  the  free  passage 
afforded  the  displaced  intestine  back  to  the  abdomen  will  almost 
always  preclude  this  difficulty.  Dr.  Mcigs^  relates  a  case  occurring 
during  labor,  in  which  the  progress  of  the  parturient  process  was 
checked  by  a  large  mass  of  intestines  until  he  succeeded  in  reducing 
the  hernia.  lie  says,  with  reason,  that  in  such  a  case  strangulation 
or  contusion  was  to  have  been  feared. 

One  very  momentous  aspect  in  which  these  hernife  must  be 
viewed  is  in  relation  to  puncture  of  vaginal  tumors,  occurring 
during  labor,  for  ascertaining  their  contents.  Xo  such  explorative 
means  should  be  resorted  to  without  careful  differentiation  of 
vaginal  hernire  of  all  descriptions,  and  especially  of  that  of  which 
we  have  last  spoken.  The  peculiar  sensation  to  the  touch,  of  a  tumor 
filled  with  air,  a  resonant  sound  upon  percussion,  the  detection  of 
peristaltic  movements,  and  careful  exclusion  of  all  other  forms  of 
tumor  which  might  appear  under  the  circumstances,  will  serve  to 
avoid  error.  When  it  is  borne  in  mind  that  vaginal  tumors  are 
very  near  the  inflated  intestines,  and  that  they  often  yield  to  the 
touch  an  airy  sensation,  it  will  be  appreciated  that  great  caution  is 
necessary  in  arriving  at  a  diagnosis.  Even  when  the  investigator 
feels  positive  in  his  diagnosis,  it  is  always  advisable  to  test  the 
question  by  capillary  puncture.  Should  an  intestine  be  punctured 
by  the  little  needle  employed,  no  evil  will  result. 

'  Notes  to  Colombat,  p.  211. 


176  PROLAPSUS    VAaiN^E. 

Treatment  of  Vaginal  Prolapse  and  Heryiia. — Should  the  accident 
have  occurred  suddenly,  reduction  should  at  once  be  accomplished, 
and  the  recurrence  of  the  displacement  prevented  by  appropriate 
means.  The  bladder  and  rectum  being  evacuated,  the  patient 
should  be  placed  in  the  knee-chest  position,  and,  the  fingers  being 
well  oiled,  steady  pressure  should  be  exerted  in  coincidence  with 
the  axis  of  the  inferior  strait,  until  the  prolapsed  part  is  returned 
to  its  place.  In  the  case  of  enterocele  already  referred  to  as  treated 
by  Prof.  Meigs,  the  patient  was  placed  upon  the  left  side,  and  taxis 
being  practised,  the  mass  suddenly  slipped  above  the  superior  strait, 
into  which  the  next  uterine  contraction  forced  the  child's  head. 
To  prevent  a  relapse  the  pelvis  should  be  elevated,  the  patient  kept 
perfectly  quiet,  tenesmus,  if  present,  relieved  by  the  use  of  opium, 
and  the  vagina  constricted  by  astringent  injections. 

But  sudden  cases  of  vaginal  prolapse  and  hernia  are  very  rarely 
met  with.  It  is  usually  those  which  have  slowly  and  gradually 
established  themselves  that  we  are  called  upon  to  treat,  and  these 
are  always  obstinate  and  rebellious.  The  means  at  our  command 
for  overcoming  such  cases  are  the  following: 

1st.  Local  astringents  and  tonics; 
2d.  Supplementary  support ; 
3d.  Surgical  procedures. 

The  first  of  these  may  be  efi:ectual  in  slight  cases,  but  in  those 
of  graver  character  they  will  prove  insufficient.  The  tone  and 
strength  of  the  vagina  may  be  temporarily  restored  by  the  use  of 
injections  of  large  amounts  of  cold  water  medicated  wntli  tannin, 
alum,  or  zinc,  emplo3^ed  night  and  morning.  The  patient  should 
be  sent  during  the  summer  to  a  watering-place,  where  sea-bathing 
and  injections  of  sea-water  into  the  vagina  may  be  employed.  A 
very  excellent  result  will  also  sometimes  follow  the  use  of  vaginal 
suppositories  containing  one  of  the  astringents  mentioned. 

Supplementary  Support  may  be  efiected  by  an  abdominal  sup- 
porter, with  perineal  band,  and  by  the  use  of  a  properly  constructed 
pessary,  such,  for  example,  as  the  double  lever  of  Hodge  or  Smith, 
the  ring  of  IMeigs,  or  the  stem  of  Cutter. 

In  some  cases  the  globe  pessary,  a  round  ball  made  of  glass  or 
silver,  or  the  air  pessary  of  Gariel  will  be  found  to  be  very  useful, 
more  especially  where  the  bladder  or  rectum  participates  in  the 
prolapse.  But  they  must  necessarily  be  only  palliative  in  their 
results,  since  while  they  relieve  the  immediate  consequences  of  want 
of  power  in  the  canal,  they  increase  the  existing  weakness  by  con- 


TREATMENT.  177 

tinned  distention.  In  several  very  obstinate  cases  in  which  I  could 
not  for  certain  reasons  resort  to  surgical  procedures,  I  have  succeeded 
in  giving  great  temporary  relief  by  the  use  of  the  anteversion 
pessaries  represented  in  the  chapter  on  anteversion.  The  prominent 
or  supporting  arm  of  these  instruments,  making  pressure  upon  the 
vagina  just  anterior  to  the  uterus,  lifts  up  this  surface  and  thus 
sustains  it  and  the  bladder. 

Surgical  Procedures. — Of  these  there  are  three  which  may  prove 
eft'ectual.  If  a  ruptured  perineum  seem  to  produce  the  want  of 
support,  the  operation  of  perineorrhaphy  may  be  all  that  will  be 
necessary.  This  is  described  elsewhere.  In  a  certain  number  of 
cases  where  the  vaginal  displacement  has  not  resulted  in  prolapse 
of  the  uterus,  where  it  is  desired  to  exchange  a  prolapse  in  the 
third  degree  for  one  in  the  second,  and  where  from  the  advanced 
age  of  the  patient,  patency  of  the  vagina  is  no  longer  necessary, 
union  of  the  labia  majora  for  the  lower  three-quarters  of  their 
extent  has  been  practised.  This  procedure  has  received  the  name 
of  episiorrhaphy  {iniati.ov  the  labium,  and  pat??  suture).  The  oj^e-. 
ration  of  uniting  the  labia  majora,  and  thus  partially  closing  the 
vagina,  was  first  proposed  and  practised  by  Fricke,  of  Hamburg,  in 
1832.  In  1835,  he  reported  to  the  French  Academy  of  Medicine 
four  cases,  three  of  which  ended  successfully.  In  1839,  Dr.  Eli 
Geddings,  of  Charleston,  S.  C,  performed  the  operation  four  times, 
two  of  his  cases,  certainly,  and  all,  probably,  ending  successfully. 
Two  were  lost  sight  of  at  an  early  period.  After  this,  the  procedure 
was  practised  by  Scanzoni,  Roux,  Yelpeau,  Simon,  Stoltz,  and 
Malgaigne,  but  the  results  were  not  good. 

The  operation  consists  in  paring  the  edges  of  the  labia  majora, 
removing  the  labia  minora,  and  uniting  the  vivified  surfaces  by 
silver  sutures. 

If  prolapsus  uteri  have  occurred,  or  even  a  marked  degree  of 
vesical  or  rectal  displacement,  the  operation  of  elytrorrhaphy,  or 
diminishing  the  calibre  of  the  vagina,  is  the  only  procedure  vrhich 
promises  a  radical  cure.  This  operation  will  be  fully  described  in 
connection  with  prolapsus  uteri. 


12 


178  FISTULA    OF    THE    FEMALE    GENITAL    ORGANS. 


CHAPTER    X. 

FISTULA   OF  THE   FEMALE  GENITAL   ORGANS. 

Definition. — As  a  result  of  certain  traumatic  and  morbid  pro- 
cesses, the  continuity  of  the  vaginal  and  uterine  walls  may  be 
destroyed  and  communication  established  with  adjacent  viscera. 
To  the  tracts  or  passages  thus  opened,  the  name  of  fistulas  has 
been  given. 

Varieties. — These  communications  connect  the  vagina  or  uterus 
with  some  viscus  in  immediate  proximity,  for  the  natural  outlet  of 
which  they  act  vicariously,  or  with  some  neighboring  part,  as  the 
peritoneum,  the  vulva,  or  the  pelvic  areolar  tissue.  Their  varieties 
have  received  the  following  descriptive  appellations: 

Urinai^y  Fist  idee. 

Vesico-vaginal  fistula; 
Urethro-vaginal  fistula ; 
Vesico-utero-vaginal  fistula; 
Vesico-uterine  fistula; 
Uretero-uterine  fistula ; 
Uretero- vaginal  fistula. 

Fecal  Fistulce. 

Recto- vaginal  fistula; 
Entero-vaginal  fistula ; 
Recto-labial  fistula. 

Simple  Vaginal  Fistulce. 

Peritoneo- vaginal  fistula ; 
Perineo-vaginal  fistula ; 
Blind  vaginal  fistula. 

Urinary  Fistulas. 

Urinary  fistulse  may  occur  on  any  part  of  the  anterior  surface 
of  the  genital  canal  intervening  between  the  vulva  and  fundus 
uteri.  Fig.  42  displays  the  points  at  which  they  are  usually  ob- 
served. 


URINARY    FISTULA. 


179 


Vesico- Vaginal  Fistula  (2)  is  a  communication  between  the 
bladder  and  vagina,  either  at  the  trigone  or  the  bas-tbnd,  which 
may  involve  only  enough  tissue  to  admit  a  small  probe,  or  entirely 
destroy  the  vesico-vaginal  wall.  Such  an  opening  may  be  oval, 
angular,  elliptical,  or  linear  in  shape,  and  its  borders  may  be  thick 
or  thin,  soft  or  indurated,  rough  or  smooth,  pale  or  vascular. 

Fig.  42, 


Varieties  of  urinary  fistulse :   1.  Urethro- vaginal  fistula ;  2.  Vesico-vaginal  fistula  ; 
3.  Vesico-utero-vagiaal  fistula  ;  4.  Vesico-uteriue  fistula. 

Urethro-  Vaginal  Fistula  (1)  resembles- that  just  mentioned,  except 
in  the  fact  that  the  destruction  of  tissue  which  has  produced  it 
involves  the  wall  of  the  urethra,  and  not  that  of  the  bladder. 


Vesico-TJterine  Fistnlce  (4)  are  those  in  which  there  is  a  direct 
communication  between  the  bladder  and  uterus  above  the  point 
of  vaginal  attachment.  The  vagina  is  consequently  not  involved, 
and  the  urine  passing  into  the  uterus  escapes  at  the  os. 

Vesico-Utero-Vaginal  Fistulce  (Z)  Sire  those  in  the  production  of 
which  a  lesion  occurs  in  both  uterus  and  vagina,  as  is  imperfectly 
shown  by  (3).  At  the  vaginal  junction  there  is  a  perforation  of 
the  bladder,  but  this  does  not  penetrate  to  the  cavity  of  the  uterus. 
A  canal  is  created  in  its  wall,  and  through  this  tlie  urine  escapes 


180  FISTULA    OF    THE    FEMALE    GENITAL    OKGANS. 

into  the  vao-ina.  The  last  two  forms  of  iistulse  were  first  accurately 
described  by  Jobert,  who  made  of  the  last,  two  varieties,  superficial 
and  deep.  In  the  first  a  canal  is  channelled  out  on  the  vesical 
surface  of  the  cervix  uteri;  in  the  second,  the  cervix  is  to  a  greater 
or  less  extent  destroyed  by  the  process  of  sloughing,  and  through  it 
the  urine  passes.  In  the  first  form  the  lesion  is  chiefly  vesical  and 
uterine,  the  vagina  not  being  much  injured;  in  the  other  it  aflbcts 
three  organs,  tlie  bladder,  the  uterus,  and  the  vagina.  All  these 
forms  of  fistulse  have  thus  been  grouped  into  classes  by  Dr.  Boze- 
man: 

1st  Class.  Those  consisting  in  a  communication  between  the 
urethra-  and  vagina ; 

2d  Class.  Those  established  at  the  expense  of  the  trigonus  vesi- 
calis ; 

3d  Class.  Those  situated  in  the  bas-fond  of  the  bladder ; 

4th  Class.  Those  involving  the  trigone  and  root  of  the  urethra, 
the  trigone  and  bas-fond,  or  all  three  of  these  parts  together; 

6th  Class.  Those  implicating  the  cervix  uteri. 

In  some  cases,  however,  multiple  fistulas  exist,  and  no  special 
classification  can  he  made. 

Causes.— Any  influence  which  is  capable^  of  destroying  the  con- 
tinuity of  the  vaginal  walls,  either  by  mechanical,  chemical,  or  vital 
action,  would  of  eoiu'se  give  rise  to  this  condition.  Those  which 
are  found  in  actual  practice  to  have  jDroved  most  commonly  efficient, 
are  tlie  following: 

1st.  Prolonged  or  very  severe  pressure ; 

2d.  Direct  injur}' ;. 

3d.  Ulceration  or  abscess.. 

Pressure,  which  is  more  frequently  a  cause  than  any  of  the  others 
mentioned,  is  generally  produced  by  the  child's  head  remaining 
too  long  in  the  pelvis  during  labor.  This  is  beyond  all  doubt  the 
most  prolific  source  of  the  accident,  though  it  may  also  attend  a 
rapid  laljor  in  which  the  vagina  has  been  pressed  against  some 
point  of  the  pelvis  with  great  violence.  Such  pressure  produces 
sloughing  of  the  part  of  the  vagina  receiving  it,  and  at  that  spot 
a  deficiency  of  tissue  in  future  exists,  which  constitutes  a  fistula. 
The  process  of  sloughing  occurs  from  pressure  of  the  foetal  head, 
exactly  as  a  bedsore  takes  place  in  one  who  lies  for  too  long  a  time 
in  the  same  position,  the  sequence  being,  disturbed  and  retarded 
circulation,  impaired  nutrition,  and  local  death.     Or  a  puerperal 


CAUSES.  181 

vaginitis  may  be  established,  which  runs  a  violent  course,  and  may 
end  in  sloughing  after  several  weeks'  duration. 

An  involuntary  flow  of  urine  usually  announces  the  existence 
of  a  fistula  within  three  or  four  days  after  delivery,  though  when 
it  is  the  result  of  injury  inflicted  by  instruments  employed  in 
delivery,  it  may  occur  immediately.  On  the  other  hand,  the  sepa- 
ration of  the  slough,  which  will  entail  deficiency  of  tissue  and  its 
results,  may  not  take  place  until  much  later,  when  perhaps  all  fears 
are  allayed,  and  the  case  is  regarded  as  progressing  favorably. 
Jean  Louis  Petit  records  one  case  developing  its  symptoms  after 
a  month;  Jobert  one  in  which  on  the  twenty-second  day  after 
delivery  the  slough  was  found  at  the  mouth  of  the  vagina;  Adler, 
of  Iowa,  one  in  which  after  twenty-nine  days  the  slough  was  only 
partially  separated ;  and  Agnew,  of  Philadelphia,  another,  in  which 
it  separated  on  the  twenty-first  day. 

Other  agencies  which  may  create  fistulte,  but  Mdiich  have  been 
rarely  noticed  to  do  so,  are  pessaries,  stones  in  the  bladder,  fecal 
accumulation,  etc. 

Direct  injury  may  produce  the  accident  by  contusing  or  lacerat- 
ing the  vaginal  walls,  as  may  occur  during  delivery  by  the  forceps 
or  craniotomy.  •  That  these  ojjerations  when  carelessly  or  unskil- 
fully performed  may  produce  a  fistula,  no  one  will  pretend  to  deny, 
but  there  can,  with  the  evidence  now  recorded,  be  no  doubt  that 
they  have  often  been  credited  with  unfortunate  results  which  were 
in  reality  due  to  tardiness  in  their  employment.  Very  often,  where 
a  labor  has  been  allowed  to  be  prolonged  in  the  second  stage  until 
the  vitality  of  certain  points  in  the  vagina  has  become  irremediably 
impaired,  and  the  process  of  sloughing  has  been  already  inaugu- 
rated, subsequent  delivery  by  forceps  or  craniotomy  has  been  re- 
garded as  producing  fistula.  Under  such  circumstances  the  real 
morbid  agency,  prolonged  and  violent  pressure,  is  lost  sight  of,  and 
the  more  palpable  agents,  the  instruments  employed,  are  viewed  as 
the  source  of  the  accident.  The  truth  with  reference  to  this  point 
should  be  well  understood  by  every  practitioner,  for  unless  it  be  so, 
an  incompetent  person  may  shield  himself  from  merited  blame  by 
casting  censure  upon  a  consulting  physician  by  whose  efforts  the 
lives  of  both  mother  and  child  have  been  saved,  or  a  skilful  ope- 
rator may  suffer  unjustly  in  a  suit  for  malpractice. 

In  a  report  upon  this  subject  by  Mr.  I.  Baker  Brown'  to  the 
Obstetrical  Society  of  London,  in  1863,  the  following  statements 


Obstet.  Trans.,  vol.  v,  p.  23. 


182  FISTULA    UF    THE    FEMALE    GENITAL    ORGANS. 

are  made:  "With  regard  to  the  causes  of  vesico-vaginal  fistula,  of 
the  58  cases  admitted  into  the  London  Surgical  Home,  47  were  over 
24  hours  in  labor,  and  39  were  as  much  as  36  hours  or  more ;  7  were 
two  days;  16  were  three  days;  3  were  four  days;  2  were  five  days; 
2  six  days ;  and  1  seven  days. 

"  In  the  whole  number  of  cases  instruments-  were  used  in  29, 
exactly  one-half,  and  in  4  only  of  these  was  the  labor  less  than 
twenty-four  liours,  and  with  seven  exceptions  the  patient  had  been 
thirty-six  hours  or  more  in  labor  before  instruments  were  used. 

"Of  the  58  cases,  in  24  only  the  injury  happened  at  the  first 
labor;  in  7  at  the  second;  in  5  at  the  third;  in  4  at  the  fourth; 
in  6  at  the  fifth ;  in  2  at  the  sixth ;  in  5  at  the  eighth ;  in  1  at  the 
ninth ;  1  at  the  thirteenth;  1  at  the  fifteenth;  and  2  not  mentioned." 

"From  the  foregoing  statistics  it  is  evident  that  the  cause  of  the 
lesion  is  protracted  labor,  and  not  the  use  of  instruments  or 
deformity  of  the  pelvis." 

"As  a  necessary  deduction  from  what  has  been  stated,  it  follows 
that  vesico-vaginal  fistula  would  scarcely  if  ever  occur,  if  a  labor 
were  not  allowed  to  become  protracted;  and  this  is  a  point  for  the 
careful  consideration  of  practitioners  in  midwifery."  The  experi- 
ence of  Drs.  Sims,^  Emmet,  and  Bozeman^  is  confirmatory  of  that 
of  Mr,  Brown,  and  as  the  opportunities  for  observation  enjoyed  by 
these  four  practitioners  have  probably  been  as  extensive  as  those 
of  any  living  authorities,  their  evidence  may  be  regarded  as  con- 
clusive. 

It  is  a  curious  fact  that  when  for  the  relief  of  obstinate  chronic 
cystitis  a  vesico-vaginal  fistula  is  intentionally  created  by  the  knife, 
it  is  diflicult  to  keep  it  open.  In  spite  of  the  occasional  introduc- 
tion of  the  sound  for  this  purpose,  such  openings  obstinately  heal 
of  their  own  accord,  so  that  it  becomes  necessary  to  place  a  species 
of  button  or  stud  in  the  opening  to  prevent  an  issue,  which,  under 
these  circumstances,  is  undesirable.  This  case  seems  parallel  with 
that  of  perforation  of  the  tympanum,  which,  being  effected  by  an 
instrument,  heals  rapidly;  while  the  closure  of  an  opening,  the 
result  of  disease,  often  becomes  impossible. 

About  thirty  years  ago  Diefl'enbach^  recorded  a  case  of  vesico- 
vaginal fistula,  the  cause  of  which  had  been  the  presence  of  a  stone 

'  Gardner's  Notes  to  Scanzoni,  p.  503. 
^  Agnew.  Vesico-Yaorinal  Fistula. 
3  Med.  Record,  vol.  i.  321. 


SYMPTOMS.  183 

in  the  bladder,  complicating  labor;  and  Baker  Brown*  mentions 
another  instance  of  this  kind  in  1861. 

Ulceration  or  Abscess. — The  vaginal  walls  may  be  eaten  through 
by  cancerous,  syphilitic,  or  phagedenic  ulcers,  or  a  communication 
may  be  established  by  an  abscess  opening  into  the  vagina  and  into 
a  neighboring  viscus  or  part.  In  one  case  I  found,  in  the  autof)sy 
of  a  woman  who  had  died  from  a  profuse  diarrhoea,  in  which  the 
feces  had  passed  by  the  vagina,  a  communication  created  by  abscess 
between  the  caput  coli  and  that  canal. 

Cancerous  disease  often  destroys  the  vesieo- vaginal  septum,  but 
as  these  fistulse  are  irremediable,  and  attend  upon  a  rapidly  fatal 
disorder,  they  attract  little  attention  in  themselves.  Lastly,  certain 
diseases  producing  deficiency  of  nutrition,  as,  for  example,  the 
continued  fevers,  may  cause  sloughing  of  the  vaginal  walls  or  pha- 
gedenic ulceration. 

Symptoms, — ^The  prominent  symptoms  and  signs  of  urinary  fis- 
tulse may  be  grouped  under  three  heads :  first,  those  furnished  by  a 
characteristic  discharge;  second,  those  arising  from  the  irritant 
action  of  such  discharge  upon  the  part  over  which  it  flows ;  and 
third,  those  afforded  by  physical  examination. 

Sometimes  the  escape  of  urine  is  so  excessive  as  to  preclude  the 
necessity  of  a  discharge  'per  vias  naturales ;  at  others  the  excretion 
is  partly  evacuated  by  the  natural  and  partly  by  the  vicarious  out- 
let. This  symptom  shows  at  times  eccentric  variations.  When  the 
fistula  is  seated  in  the  urethra  the  bladder  may  be  distended  with- 
out loss,  which  may  take  place  into  the  vagina  during  micturition. 
Sometimes  while  in  the  horizontal  posture  the  escape  will  cease,  the 
anterior  vesical  wall  being  pressed  by  the  intestines  against  the  bas- 
fond  so  as  to  close  the  opening,  and  in  other  cases,  where  the  fistula 
is  above  the  orifice  of  the  ureters,  the  flow  will  take  place  while  the 
patient  lies,  and  cease  when  she  stands. 

The  passage  of  excrementitious  material  through  a  canal  and 
over  a  tissue  not  intended  by  nature  to  tolerate  it,  produces  inflam- 
matory action,  pruritus,  eruptions,  and  excessive  irritability.  In 
urinary  fistulse  the  vulva  and  thighs  are  usually  red,  excoriated, 
and  covered  by  a  vesicular  eruption.  The  vagina  is  sometimes 
covered  by  urinary  concretions,  and  a  highly  offensive  odor  ema- 
nates from  the  patient's  body. 

The  general  health  is  very  likely  in  time  to  give  way,  and  hys- 
teria, chlorosis,  and  graver  disorders,  often  show  themselves. 

'  Op.  cit. 


184  FISTULA    OF    THE    FEMALE    GENITAL    ORGANS. 

Physical  Signs. — If  the  fistulous  orifice  be  a  large  one,  even  a 
superficial  examination  by  touch,  the  patient  lying  upon  her  back, 
will  o-enerally  serve  to  reveal  the  nature  and  extent  of  the  lesion. 
It  is  difterent,  however,  with  very  small  fistulce,  which  will  some- 
times elude  the  most  careful  investigation.  For  their  detection 
Sims's  speculum  should  be  employed,  and  in  many  cases  it  will  be 
found  advisable  to  place  the  woman  in  the  knee-elbow  position, 
instead  of  that  on  the  side,  before  its  introduction,  and  to  have  the 
buttocks  and  labia  pulled  apart  by  the  hands  of  assistants.  Even 
this  method  is  not  effectual  in  revealing  the  opening  if  it  be  very 
minute.  Under  these  cii'cumstances  the  bladder  should  be  injected 
with  water,  and  its  escape  into  the  vagina  carefully  watched  for. 
Sometimes,  by  this  means,  a  capillary  opening,  just  at  the  junction 
of  the  vagina  and  cervix,  will  be  detected.  Kiwisch,  Meyer,  Veit, 
and  others  have  used  for  this  purpose  water  colored  with  substances 
which  will  impart  a  bright  tinge  to  it.  Infusion  of  cochineal, 
madder,  or  indigo,  may  be  thus  employed.  The  opening  being 
once  detected,  the  probe  and  finger  will  readily  reveal  the  course, 
extent,  and  terminus  of  the  tract. 

Complications. — The  complications  which  these  fistulas  develop 
are  vaginitis,  vulvitis,  stricture  of  urethra  and  vagina,  and  some- 
times endometritis  and  periuterine  inflammation.  The  most  con- 
stant and  important  of  these  is  the  formation  of  bands,  which  con- 
tract the  vagina,  and  which  often  require  severance  before  operative 
procedure  can  be  practised. 

Pkognosis. — Previous  to  the  year  1852,  the  prognosis  of  all  cases 
in  which  the  orifice  acted  as  a  vicarious  outlet,  for  example,  vesico- 
vaginal, recto-vaginal,  and  vesico-utero-vaginal  fistulse,  was  emi- 
nently unfavorable,  for  they  very  rarely  undergo  spontaneous 
recovery,  and  the  means  of  cure  at  our  command  up  to  that  time 
were  uncertain  and  full  of  discouragement.  In  1860,  Dr.  Sims' 
stated,  "  Of  261  cases  of  vaginal  fistula  (vesical  and  rectal)  216  have 
been  permanently  cured  by  the  silver  wire  suture,  36  are  curable, 
and  9  incurable.  Every  case  is  curable  when  the  operation  is  prac- 
ticable, provided  there  is  no  constitutional  vice  to  interfere  with 
the  powers  of  union.     Success  is  the  rule,  failure  the  exception." 

The  enlarged  experience  of  the  jirofession  has  fully  corroborated 
these  assertions,  made  fourteen  years  ago,  and  it  may  now  be 
accepted  as  a  true  statement  as  to  the  prognosis  of  all  fistulfe  of 


Gardner's  Notes  to  Scanzoni,  p.  515. 


HISTORY.  185 

the  female  genital  organs  except  cases  of  vesico-uterine  fistula, 
in  which  the  point  of  rupture  is  out  of  reach  of  surgical  inter- 
ference. 

History. — The  history  of  this  subject  dates  back  only  to  the 
sixteenth  century,  when  attention  was  called  to  it,  and  a  plan  of 
treatment  proposed  by  Ambrose  Pare.  Before  the  discovery  of  the 
forceps,  the  accident  must  have  been  one  of  very  frequent  occurrence, 
for  then  powerless  labor  was  not  under  the  control  of  the  obstetri- 
cian, except  by  resort  to  a  set  of  badly  constructed  instruments  for 
craniotomy,  which  in  themselves  presented  serious  dangers  of 
laceration.  The  symptoms  which  mark  its  existence  are  so  palpable 
and  distressing  that  it  does  not  require  a  physician  to  diagnosticate 
it,  and  no  case  of  any  gravity  could  have  escaped  notice.  And  yet, 
curious  to  relate,  there  are  few  diseases  to  which  woman  is  liable, 
which  have  received  so  little  notice  at  the  liands  of  the  ancients. 
Even  pelvic  cellulitis  and  other  aftections,  which  have  but  lately 
attracted  attention  from  the  physicians  of  our  day,  are  distinctly 
alluded  to  by  the  writers  of  the  Greek  school;  but  this  one,  so 
annoying,  so  destructive  of  happiness,  and  so  urgent  in  its  demands 
for  relief,  has  received  scarcely  any  mention.  It  is  true  that  Hip- 
pocrates makes  some  slight  allusion  to  involuntary  discharge  of 
urine  following  difficult  labors,  but  his  remarks  upon  the  condition 
are  meagre  and  unimportant. 

I  do  not  claim  to  have  made  a  full  examination  of  the  writings 
of  the  Greeks  and  Romans  with  reference  to  the  subject,  but  base 
the  statement  which  I  have  advanced  chiefly  upon  the  fact  that  the 
two  great  compilers  of  their  periods,  Aetius  and  Paulus  ^gineta, 
make  no  mention  of  it.  The  work  of  Aetius  upon  diseases  of 
women  (Tetrabiblos  IV)  is  made  up  of  quotations  from  Soranus, 
Aspasia,  Galen,  Philumenus,  Archigenes,  Leonidas,  Rufus,  Phila- 
grius,  Asclepiades,  in  fact  of  all  worthy  of  note,  whose  writings 
were  stored  in  the  Alexandrian  Library,  which  was  the  seat  of  his 
labors.  By  none  of  these  is  mention  made  of  the  affection.  The 
works  of  Pan]  of  ^gina,  enriched  as  they  have  been  by  the  copious 
notes  of  Dr.  Adams,  their  translator,  are  equally  silent;  and  the 
researches  of  those  who  have  examined  the  writings  of  the  Arabians 
record  no  discovery  of  any  description  of  it  at  their  hands.  At  any 
rate,  it  is  quite  certain  that  no  contributions  to  the  treatment  of 
the  difficulty  were  made  by  the  writers  of  the  Greek,  Roman,  or 
Arabian  schools. 

Beginning  at  the  seventeenth  century,  I  will  allude  only  to  those 


186  FISTULA    OF    THE    FEMALE    GENITAL    ORGANS. 

who  have  made  some  advance  in  treatment,  and  not  endeavor  to 
record  the  names  of  all  who  have  reported  cures,  or  advised  pro- 
cedures which  have  not  been  of  subsequent  utility. 

Before  proceeding  with  the  historical  sketch  which  ensues  I 
would  draw  the  attention  of  the  reader  to  two  interesting  facts 
which  it  will  demonstrate.  It  will  be  seen  that  for  centuries  steady, 
persevering,  and  systematic  eiforts  have  been  made  to  render  this 
revolting  malady  curable,  and  that,  as  has  so  often  been  the  case  in 
other  great  discoveries,  the  minds  of  several  investigators  pursued 
the  same  course  until  at  last  success  was  reached.  After  a  discovery 
has  been  made  it  is  always  easy  to  point  out  the  elements  upon 
which  it  rests  for  its  success,  and  even  to  follow  the  process  of 
reasoning  by  which  each  in  turn  was  supplied.  There  can  be  no 
doubt  that  the  three  elements  necessary  for  successful  treatment  of 
the  lesion  which  we  are  considering,  were: 

1st.  A  means  for  exposing  the  fistula  to  view  and  manipnlation : 

2d.  A  suture  which  would  remain  in  place  without  causing  in- 
flammation ; 

3d.  A  means  of  disposing  of  the  urine  during  the  process  of  cure. 

From  the  time  that  Par^  suggested  a  plan  of  treatment,  it  will 
be  noticed  that  surgeons  brought  these  three  means  of  cure  to  their 
aid.  But  they  emploj^ed  them  separately,  some  using  one  of  them, 
some  another,  and  others  still,  combining  two.  It  was  not,  how- 
ever, till  the  time  of  Gosset,  in  1834,  that  the  three  were  combined 
by  the  same  operator. 

In  1570,  Ambrose  Par^  proposed  the  closure  of  vcsico-vaginal 
fistulce  by  a  retinaculum.  In  1660,  Roonhuysen,  of  Amsterdam, 
used  a  speculum,  through  which  he  pared  the  edges  of  fistulse  and 
united  them  by  a  needle.  In  1720,  Voelter,  of  Wurtemberg,  advised 
a  needle,  needle-holder,  suture  by  silk  or  hemp,  and  a  catheter.  In 
1792,  Fatio,  of  Basle,  operated  by  twisted  suture,  placing  his  patients 
in  the  lithotomy  jDosition.  In  1804,  Dessault  used  a  vaginal  plug 
and  catheter  in  the  bladder.  In  1812,  Naegel^,  of  Wurtemberg, 
scarified  the  edges  by  scissors,  used  needles  to  approximate  them, 
and  employed  the  interrupted  suture.  In  1817,  Schreger,  of  Ger- 
many, placed  the  patient  on  the  abdomen,  scarified  the  edges,  and 
used  interrupted  suture.  In  1825,  Lallemand,  of  France,"applied 
nitrate  of  silver  to  the  edges  of  the  fistula,  and  approximated  them 
by  a  "sonde  erigne"  passed  through  the  bladder,  and,  of  fifteen 
cases,  cured  four.  In  1829,  Roux,  of  France,  tried  twisted  suture 
with  metallic  bars  and  ordinary  thread.  In  1834,  Gosset,  of 
London,  combined  the  knee-elbow  position,  levator  perinei  specu- 


HISTORY.  187 

lum,  metallic  sutures,  and  catheter  permanently  kept  in  the  bladder. 
In  1836,  Beaumont^  employed  the  quilled  or  clamp  suture.  In  1837, 
Jobert  de  Lamballe  resorted  to  autoplasty,  transplanting  a  piece 
from  the  labia,  buttocks,  or  thighs.  In  1838,  Wutzer,  of  Bonn, 
placed  his  patients  on  the  abdomen,  pared  the  edges  of  the  fistula, 
and  approximated  them  by  insect  needles  and  figure-of-8  suture. 
To  expose  the  fistula  the  perineum  was  held  up  by  a  hook  and  the 
labia  drawn  aside  by  assistants.  In  1839  and  1840,  Ilayward,  of 
Boston,  U.  S.,  reported  three  cases  cured  by  vivifying  the  edges  and 
closing  with  silk  suture.  This  surgeon  introduced  a  notable  im- 
provement, and  aided  in  the  final  success  by  vivifying  not  only  the 
borders  of  the  fistula  but  the  neighboring  vaginal  surfaces.  In 
1844,  Chelius^  placed  his  patients  in  the  knee-elbow  position.  In 
1846,  Metzler,^  of  Prague,  employed  the  levator  perinei  speculum, 
perforated  balls  the  size  of  shot,  the  knee-elbow  position,  gilded 
needles,  and  a  permanent  catheter.  In  1847,  Mettauer,  of  Virginia, 
employed  the  catheter  and  leaden  sutures  with  such  success  that  he 
was  led  to  make  the  following  statement:  "I  am  decidedly  of  the 
opinion  that  every  case  of  vesico-vaginal  fistula  can  be  cured,  and 
my  success  justifies  the  opinion."  In  1852,  Jobert  de  Lamballe 
adopted  his  method,  styled  "reunion  autoplastique  par  glissement," 
which  consisted  in  giving  sutficient  vaginal  tissue  for  union,  by 
cutting  transversely  through  the  vagina,  at  its  junction  with  the 
uterus,  in  a  line  with  the  fistula.  In  1852,  Marion  Sims,*  of  the 
United  States,  combined  the  three  essentials  for  success,  the 
speculum,  the  suture,  and  the  catheter,  and  placed  the  operation  at 
the  disposal  of  the  profession. 

The  discoveries  to  which  he  laid  special  claim  were  these: 

1st.  A  method  by  which  the  vagina  could  be  distended  and  ex- 
plored ; 

2d.  A  suture  not  liable  to  excite  inflammation  or  ulceration; 

3d.  A  method  of  keeping  the  bladder  empty  during  the  process 
of  cure. 

Entering  the  field  almost  as  early  as  Sims,  Simon,  of  Germany, 
greatly  aided  in  systematizing  the  operation,  and  has  been  second 
to  no  one  else  in  improving  it. 

From  a  study  of  the  literature  of  this  subject  it  is  made  as 
evident  as  written  testimony  can  make  any  history  of  the  past,  that 


•  Med.  Gaz.,  Dec.  3d,  1836,  p.  355.  2  Agnew,  op.  cit.,  p.  15. 
^  Schuppert  on  Yes.-Yag.  Fistula,  p.  41. 

*  Anier.  Journ.  Med.  Sci.,  1852. 


188  FISTULA    OF    THE    FEMALE     GENITAL    ORGANS. 

not  only  did  several  investigators  combine  two  of  these  elements 
of  success  in  their  operations,  but  that  two,  Grosset,  in  England,  and 
twelve  years  afterwards  Metzler,  in  Germany,  absolutely  combined 
all  three.  It  is  also  made  equally  evident  that  they  either  tailed 
to  recognize  the  importance  of  what  they  had  attained,  or  did  not 
impress  its  value  upon  others,  so  that  humanity  could  profit  by  it. 
Dr.  Gosset's  procedure  is  thus  described  in  his  own  words  in  the 
first  volume  of  the  London  Lancet,  page  846, 

"Ha vino;  placed  the  patient  resting  upon  her  knees  and  elbows, 
upon  a  firm  table  of  convenient  height  covered  with  a  folded 
blanket,  the  external  parts  were  separated  as  much  as  possible  by 
a  couple  of  assistants,  so  as  to  bring  the  fistula,  which  was  imme- 
diately above  the  neck  of  the  bladder,  into  view.  I  seized  with  a 
hook  the  upper  part  of  the  thickened  edge  of  the  bladder  Avhich 
surrounded  the  opening,  and  proceeded  with  a  spear-shaiied  knife 
to  remove  an  elliptical  portion,  which  included  the  whole  of  the 
callous  lip  surrounding  the  fistula,  the  long  angle  of  the  ellipsis 
being  transversel3\  This  was  readilj'  efl:ected ;  but,  in  consequence 
of  the  very  contracted  state  of  the  parts,  the  next  steps  of  the 
operation  were  with  difficulty  executed;  and  I  should  not  have 
succeeded  in  passing  the  sutures,  had  I  not  used  needles  very  much 
curved,  and  a  needle-holder  which  I  could  disengage  at  pleasure, 
the  needles  being  withdrawn  with  a  pair  of  dissecting  forceps  after 
the  holder  Avas  removed.  In  this  way  three  sutures  were  passed ; 
and  afterwards,  by  twisting  the  wire,  the  incised  edges  were 
brought  into  contact  and  retained  in  complete  apposition  until  they 
had  firmly  united.  One  of  the  sutures  was  removed  at  the  end  of 
the  ninth  day,  the  second  at  the  end  of  the  twelfth  day,  and  the 
third  was  allowed  to  remain  until  three  weeks  had  elapsed.  After 
the  operation  the  patient  was  put  to  bed  and  desired  to  lie  on  her 
face,  an  elastic  gum  catheter,  having  a  bladder  secured  to  its 
extremity  for  the  reception  of  the  urine,  having  been  introduced 
and  retained  by  means  of  tapes.  She  had  not  the  slightest  dis- 
charge of  urine  through  the  vagina  after  the  operation,  which 
completely  succeeded  in  restoring  the  healthy  functions  of  the  part. 
The  advantages  of  the  gilt  wire  suture  are  these:  it  excites  but 
little  irritation,  and  does  not  appear  to  induce  ulceration  with  the 
same  rapidity  as  silk  or  any  other  material  with  which  I  am 
acquainted;  indeed,  it  produces  scarcely  any  such  eflfect,  except 
when  the  parts  brought  together  are  much  stretched.  You  can, 
therefore,  keep  the  edges  of  a  wound  in  close  contact  for  an 
indefinite  length  of  time,  by  which  the  chances  of  union  are  greatly 


HISTORY.  189 

increased,  I  have  used  it  now  in  very  many  operations,  as  after 
extirpation  of  the  breasts,  tumors  of  various  kinds,  and  for  bringing 
the  lips  together  after  the  removal  of  a  cancerous  growth,  in  all  of 
which  cases  it  answered  extremely  well." 

The  method  of  Metzler  was  published  in  the  Prague  Viertel 
Jahrcsschrift  for  1846,  under  the  title  of  "Pathology  and  Treatment 
of  Urinary  and  Vesico-Yaginal  Fistulas,  with  a  method  of  treatment 
easily  executed  and  completely  successful."  I  transcribe  his  article 
from  the  brochure  of  Dr.  Schuppert  already  alluded  to. 

"  To  perform  the  operation  successfully,  it  is  of  much  importance 
to  have — 1st,  a  speculum,  serving  as  a  dilator  of  the  vagina.  Such 
an  instrument  consists  of  a  grooved  conical  blade,  five  and  a  half 
inches  long,  three  inches  wide  at  the  anterior  part,  one-half  an  inch 
wide  at  the  posterior.  The  end  of  the  s[)eculum  is  bent  under  at  a 
right  angle,  and  protected  with  wood  for  the  handle.  The  instru- 
ment is  best  when  made  of  silver,  and  polished  to  reflect  the  liglit 
on  the  parts  to  be  operated  upon.  2d,  an  apparatus  consisting  of 
perforated  clamps,  gilded  needles,  and  an  instrument  called  '  Posen- 
kranzwerkzeng,'  consisting  of  perforated  balls  of  the  size  of  large 
shot,  by  which  the  clamps  are  held  in  contact.  After  the  j^atient 
is  placed  on  her  knees  and  elbows,  the  dilator  is  introduced  into 
the  vagina  and  given  to  an  assistant,  who  in  holding  it  presses  it 
against  the  rectum.  The  edges  of  the  fistula  are  then  pared  oft', 
which  may  be  accomplished  with  curved  scissors.  One  line  and  a 
half  from  the  mucous  meml)rane  of  the  vagina  and  half  a  line  from 
the  edge  of  the  bladder  have  to  be  cut  ofi";  the  needles  are  then 
applied,  and  the  wound  held  in  coaptation  by  the  clamps;  a  female 
catheter  is  introduced  into  the  bladder  by  the  urethra,  and  the 
catheter  fastened  by  a  T  bandage." 

From  what  has  been  said  thus  far  it  would  appear  that  Dr.  Sims 
was  forestalled  in  all  the  details  of  the  discovery  by  which  he  has 
rendered  vaginal  fistulse  curable.  To  a  certain  extent  this  is 
unquestionably  true,  but  only  as  regards  the  theory  of  the  matter. 
Before  his  publications  the  unfortunate  women,  whose  lives  were 
rendered  miserable  by  fistulas  through  the  vaginal  wall,  were 
virtually  almost  as  hopelessly  aftected  as  they  were  before  Gosset 
and  Metzler  appeared  in  the  field. 

Velpeau,^  in  1839,  thus  speaks  of  cure  of  these  fistula:  "To 
abrade  the  borders  of  an  opening,  when  we  do  not  know  where  to 
grasp  them;  to  shut  it  up  by  means  of  needles  or  thread,  when  we 

'  Operative  Surgery. 


190  FISTULA    OF    THE    FEMALE    GENITAL    ORGANS. 

have  no  point  apparently  to  secure  them;  to  act  upon  a  movable 
partition  placed  between  two  cavities,  hidden  from  our  sight,  and 
upon  which  we  can  scarcely  find  any  purchase,  seems  to  be  calcu- 
lated to  have  no  other  result  than  to  cause  unnecessary  suffering  to 
the  patient."  Vidal  de  Cassis^  says:  "I  do  not  believe  that  there 
exists  in  the  science  of  surgery  a  well  authenticated  complete  cure 
of  vesico-vaginal  fistula."  Malgaigne,^  in  1854,  says:  "But  the 
truly  rational  method,  that  which  at  present  offers  the  greatest 
facility  and  efficacy,  and  the  only  one  which  should  be  applied  in 
all  cases  of  fistula  of  large  size,  is  the  suture  by  the  procedure  of 
Jobert." 

Wutzer  reported  the  following  as  the  statistics  which  he  had 
collected  ;^  "  20  cases  of  vesico-vaginal  fistula  were  subjected  to  48 
operations — among  which  were  elytroplastie,  episioraphie,  cauteri- 
zation, sutures,  interrupted  or  twisted,  and  both — and  only  two 
cured !" 

This  was  the  real  state  of  science  with  reference  to  this  oppro- 
brium chirurgice  when  Marion  Sims,  by  combining  and  utilizing  the 
three  essentials  for  success,  gained  it,  and  rendered  the  operation 
practicable  for  all  surgeons.  It  must  not  be  supposed  that  '^le 
availed  himself  of  the  results  obtained  by  his  predecessors.  All 
that  he  attained  was  arrived  at  by  hard  and  original  labor. 
Indeed,  no  one  can  read  his  address  upon  "  Silver  Sutures  in 
Surgery,"  delivered  before  the  New  York  Academy  of  Medicine, 
in  1857,  without  being  struck  by  liis  want  of  familiarity  with  the 
antecedent  literature  of  the  subject  of  his  discourse. 

I  would  not  be  understood  as  claiming  for  America  in  this 
matter  more  than  she  really  deserves — the  establishment  of  the 
method  of  cure  upon  a  firm  and  certain  basis.  To  claim  more  than 
this,  would  be  to  ignore  the  plain  teaching  of  history.  To  France 
belongs  the  inception;  to  England  the  glory  of  having  absolutely 
made  the  discovery,  although  she  did  not  appreciate  the  fact ;  to 
Germany,  next  to  America,  the  credit  of  having  specially  advanced 
and  perfected  reliable  operative  procedures.  In  that  country  to- 
^^Yi  ^^y  the  method  of  Simon,  success  even  in  the  gravest  cases  has 
become  the  rule  and  failure  the  rare  exception. 

Since  the  first  publication  of  Sims's  method,  numerous  modifi- 
cations of  it  have  been  jmt  into  practice  both  in  this  country  and 
Europe,  and  Dr.  Sims  himself  has  altered  his  plan  of  operating 

'  Pathol opie  Externe.  «  Manuel  de  M6d.  Op6rat. 

"  Med.  Record,  vol.  i,  p.  322. 


TREATMENT.  191 

very  much.  The  principle  which  he  demonstrated  is,  however 
the  same,  and  the  modifications  of  the  operation  all  act  in  develop- 
ing it. 

In  this  country,  the  operation  is  commonly  performed,  not  by 
specialists  alone,  but  by  practitioners  in  every  walk  of  the  profes- 
sion, and,  thanks  to  the  extreme  simplicity  of  Sims's  procedure,  it  is 
no  longer  looked  upon  as  a  difficult  undertaking,  requiring  sj^e- 
cial  skill  and  experience.  It  is  at  the  present  day  certainly  very 
difficult  to  appreciate  the  statement  of  a  physicia^n'  of  Ireland,  that 
"he  unfortunately  had  the  opportunity  of  seeing  a  great  number 
of  fistulas,  and  a  great  number  of  operations,  and  his  experience 
had  been  that  the  vast  majority  of  them  proved  unsuccessful." 

lleans  for  Obtaining  a  Natural  Cure. — "Within  a  few  days  after 
delivery  the  obstetrician  is  generally  made  aware  of  the  existence 
of  vesico- vaginal  fistula  by  a  steady  and  involuntary  dripping  of 
urine.  As  soon  as  this  is  evident  a  Sims's  stationary  catheter 
should  be  placed  in  the  bladder,  the  vagina  frequently  syringed 
out  with  warm  water  to  lessen  inflammatory  action,  and  the 
patient  kept  in  the  abdominal  decubitus,  in  order  that  a  repair  of 
the  injury  may  be  accomplished  by  the  efltbrts  of  nature.  This  is 
all  that  can  be  done  at  this  time,  for  it  is  too  early  to  resort  to 
suture,  and  the  lochial  discharge  would  be  interfered  with  by  a 
tampon  intended  to  aid  in  the  cure.  The  operation  by  suture 
should  not  be  undertaken  before  the  immediate  results  of  partu- 
rition have  passed  oif  and  the  fistula  has  assumed  a  permanent  size 
and  character. 

Treatment. 

The  methods  at  our  command  for  curing,  or,  where  cure  is  im- 
possible, obviating  the  inconveniences  due  to  fistulas  of  the  female 
urinary  apparatus,  are — 

1st.  Cauterization; 

2d.  Suture; 

3d.  Elytroplasty ; 

4th.  Occlusion  of  the  vagina  or  uterus. 

Cauterization. 

This  once  favorite  method  of  treating  all  varieties  of  these  fis- 
tulse  has  now  almost  entirely  fallen  into  disuse  under  the  influence 
of  improved  methods  by  suture.     Malgaigne  probably  gives  this 


Remarks  by  Dr.  Cronyn  before  the  Surgical  Society  of  Ireland,  March  15, 1872. 


192  FISTULA    OF    THE    FEMALE    GENITAL    ORGANS. 

means  its  proper  place  when  he  declares  that  it  should  be  em- 
ployed only  in  those  cases  where  the  fistula  is  scarcely  perceptible. 
Even  in  such  cases  Sims's  operation  is  far  preferable,  and  cauteriza- 
tion should  be  employed  only  where  some  special  circumstance,  such 
as  want  of  skill  or  of  the  proper  instruments,  forces  the  operator  to 
resort  to  it.  The  performance  of  it  is  very  simple.  Sims's  speculum 
being  passed  so  as  to  expose  the  fistulous  spot,  its  borders  should 
be  thoroughly  touched  with  a  pointed  stick  of  nitrate  of  silver  or 
the  actual  (;autery.  This  should  not  be  repeated  before  the  slough 
created  has  separated,  and  an  opportunity  been  allowed  for  granu- 
lation to  fill  up  the  opening. 

To  check  the  flow  of  urine  through  the  fistulous  orifice  and  sup- 
port the  vaginal  and  vesical  walls  during  the  process  of  granulation, 
a  small  tampon  of  cotton,  a  Gariel's  air  pessary,  or  a  glass  vaginal 
plug,  like  that  delineated  in  Fig.  38,  should  be  kept  in  the  vagina, 
and,  to  prevent  distention  of  the  bladder,  a  sigmoid  catheter  should 
be  permanently  retained. 

Suture. 

Preparation  of  the  Patient. — No  operation  in  surgery  more  urgently 
demands  a  good  constitutional  condition,  as  an  element  of  success, 
than  this.  Should  the  patient's  health  not  be  good,  and  her  blood- 
state  be  abnormal,  a  visit  to  the  country,  exercise,  and  fresh  air, 
with  vegetable  and  mineral  tonics,  will  do  a  great  deal  towards 
avoidance  of  failure.  At  the  same  time  the  vagina  should  be 
regularl}^  syringed  with  warm  water  to  overcome  local  inflamma- 
tion, and  insure  cleanliness.  Should  the  disorder  which  caused  the 
destruction  of  the  vaginal  wall  have  produced  as  a  complication 
cicatricial  bands  in  the  canal,  these  should  be  cut,  from  time  to 
time,  and  allowed  to  heal  over  a  glass  vaginal  plug,  and  if  contrac- 
tion have  taken  place  in  the  urethra,  it  should  be  overcome  by 
bougies.  Before  the  time  of  the  operation  the  bowels  should  be 
thoroughly  evacuated  by  a  cathartic,  and  on  the  day  of  its  perform- 
ance very  little  food  should  be  taken,  for  fear  that  the  long  continued 
use  of  an  anoesthetic  might  produce  vomiting,  which  would  tear  out 
the  sutures. 

Sims's  Operation. — This  operation  may  be  divided  into  three 
]3arts : 

1st.  Paring  the  edges  of  the  flstula; 

2d.  Passing  sutures  through  them ; 

3d.  Approximating  them  and  securing  the  sutures. 


TREATMENT.  193 

The  patient,  being  placed  upon  a  table  two  and  a  half  by  four 
feet,  which  is  covered  by  folded  blankets,  is  brought  under  the 
influence  of  an  anaesthetic,  and  placed  in  the  following  position. 
She  is  made  to  lie  on  the  left  side,  with  the  thighs  bent  at  about 
right  angles  with  the  pelvis,  the  right  a  little  more  flexed  than  the 
left.  The  left  arm  is  placed  behind  her  back,  and  the  chest  brought 
flat  down  upon  the  table  so  that  the  sternum  may  touch  it.  The 
assistant  who  is  to  hold  the  speculum,  which  is  then  introduced, 
does  so  with  the  right  hand,  while  with  the  left  he  elevates  the 
right  side  of  the  nates.  The  table  should  be  so  arranged  that  a 
bright  and  steady  light  may  fall  into  the  vagina,  which  being  then 
fully  distended,  will  be  seen  throughout  its  extent,  except  where  it 
is  obscured  by  the  speculum. 

The  operator,  having  near  him  all  the  instruments,  etc.,  which 
he  will  require,  places  his  assistants  thus:  one  holds  the  speculum, 
another  administers  the  anaesthetic,  and  a  third  stands  ready  at  his 
right  hand  to  remove  the  blood  accumulating  in  the  vagina,  by 
means  of  sponges,  in  the  sponge-holders.  Fig.  47,  which  are  rapidly 
washed  in  a  basin  of  water  that  stands  by  his  side,  to  be  used 
again.  A  fourth  assistant,  if  attainable,  may  be  well  employed  in 
handing  the  instruments  as  they  are  required.  All  being  ready,  he 
proceeds  with  the  first  step  of  the  operation. 

Paring  the  Edges  of  the  Fistula. — The  edge  of  the  fistula,  at  the 
point  which  is  deemed  most  difiicult  of  access  and  manipulation, 
is  caught  by  the  tenaculum,  or  with  what  I  much  prefer,  the  tooth 
forceps,  shown  in  Fig.  25,  and  held  up.     Then  with  a  pair  of  long- 
Fig.  43. 


Curved  scissors. 
Fig.  44. 


Bistoury  for  paring  edges  of  fistula. 

handled  scissors.  Fig.  43,  or  a  knife.  Fig.  44,  a  strip  is  cut,  extend- 
ing from  the  mucous  membrane  of  the  bladder  to  that  of  the  vagina, 
care  being  taken  not  to  wound  the  former. 
13 


194  FISTULA    OF    THE    FEMALE    GENITAL    ORGANS. 

Another  portion  of  the  edge  is  then  seized,  and  removed  like  the 
first.  The  wound  thus  left  should  be  one  bevelled  from  the  vesical 
surface  outwards,  and  great  care  should  be  observed  to  remove  the 
entire  border,  for  upon  this,  success  depends. 

It  is  of  great  moment  that  sufficient  tissue  should  be  removed, 

Fiff.  45. 


Fig.  46. 


Showing  bevelling  of  edges. 
a,  vesical  border ;  6,  vaginal 
border ;  c  c,  incision. 


Fiff.  47. 


Sims's  sponge-holder  with  han- 
dle nine  inches  long.    (Siius. ) 


Paring  the  edges.     (Wieland  and  Dubrisay.) 


TREATMENT.  195 

and  that  the  amount  taken  on  the  vaginal  surface  should  be  greater 
than  that  near  the  vesical.  Prof.  Simpson^  makes  tliis  point  very 
clear  by  the  following  language:  "Enter  the  point  of  your  knife 
into  the  vaginal  mucous  membrane  at  some  distance  from  the 
fistula;  then  transfix  with  your  knife  the  edge  of  the  fistula  to  the 
extent  you  intend  to  remove  it,  and  bringing  it  out  at  the  vesical 
border,  carry  it  right  and  left  fairly  round  the  opening,  so  as,  if 
possible,  to  bring  out  a  complete  circle  of  tissue." 

The  abraded  surface,  from  the  edge  of  the  fistula  to  the  point  of 
vaginal  section,  should  measure  at  least  four  lines,  one-third  of  an 
inch,  while  above,  it  should  just  touch  the  vesical  border,  not 
invading  its  mucous  membrane.  This  is  made  evident  by  Fig.  46. 
During  this  part  of  the  operation  the  sponges,  held  in  long-handled 
sponge-holders,  will  have  to  be  freely  resorted  to,  but  the  bleeding 
generally  soon  ceases,  and  the  operator  may  proceed  to  the  second 
step. 

Passing  the  Sutures. — The  sutures  are  passed  by  means  of  slightly 
curved  needles  held  in  a  pair  of  strong  forceps.  Fig.  48,  made  for 
the  purpose.  In  some  cases  the  metallic  thread,  made  of  annealed 
silver,  which  is  employed,  may  be  passed  at  once,  but  usually  silk 
threads  are  first  passed,  and  the  silver  sutures  are  attached  and 
drawn  through.  Dr.  E.  Cutter  has  recently  adopted  a  very  ingeni- 
ous method  for  avoiding  the  necessity  of  threading  the  needle,  and 
thus  having  a  piece  of  silver  wire  folded  over  so  as  to  interfere  with 
its  passage  through  the  tissues.  He  welds  the  wire  firmly  to  the 
needle  so  that  no  obstruction  exists  at  the  point  of  union.  A 
number  thus  prepared  are  in  readiness  for  each  operation. 

The  needles  which  we  employ  in  the  Woman's  Hospital  are  about 
three-quarters  of  an  inch  long,  round,  slightly  curved,  and  without 
cutting  edges  anywhere.  Dr.  John  T.  Hodgen,  of  St.  Louis,  has 
invented  a  needle  which  serves  an  excellent  purpose.  It  is  a  very 
small,  straight,  short  needle,  with  a  point  like  that  of  a  trocar.  Tliis 
passes  readily  through  the  tissues,  and  to  it  is  attached  a  delicate 
silk  thread  which  carries  the  silver  wire,  the  bent  end  of  which  is 
rubbed  down  to  small  dimensions  by  sand-paper.  The  needle, 
held  in  the  grasp  of  the  needle-holder,  should  be  passed  at  the 
angle  of  the  wound  which  is  most  difiicult  of  access,  half  an  inch 
from  the  edge  of  the  incision,  and  brought  out  at  the  vesical 


'  Diseases  of  Women. 


196 


FISTULA    OF    THE    FEMALE    GENITAL    ORGANS 


surface,  but  not  involving  its  mucous  lining.     Fig.  49  represents 
the  point  of  entrance  and  exit  of  the  needle. 


Fig.  48. 


Course  of  the  needle,  a,  vesical  border ; 
b,  vaginal  border ;  c,  point  of  entrance  of 
needle  ;  d,  point  of  exit  of  needle. 


Fiff.  50. 


a> 


Needle  held  in  forceps. 


Passing  the  needle.    (Wieland  and  Dubrisay.) 


The  point  of  the  needle  having  passed  out,  it  is  engaged  by  the 
small,  blunt  hook,  Fig.  54,  until  it  can  be  seized  and  drawn  through 
by  the  needle  forceps.  Then  it  is  plunged  into  the  other  lip  and 
drawn  out  half  an  inch  from  the  edge  of  the  incision.  The  ends 
of  the  silk  suture  are  then  given  into  the  charge  of  the  assistant 
holding  the  speculum,  and  another  is  passed  in  the  same  way  at 
the  distance  of  one-sixth  of  an  inch  from  the  first.  In  this  way  a 
sufficient  number  are  passed  to  close  the  fistula.  Fig.  51. 

During  this  procedure  the  edge  of  the  fistula  is  to  be  fixed  by 
the  tenaculum,  and  should  firm,  opposing  force  be  needed  to  make 
the  needles  pass,  it  may  be  given  by  that  instrument. 

When  the  needle  is  seized  by  the  forceps  and  pulled  so  as  to 


TKEATMENT. 


197 


make  the  thread  follow  it,  some  opposing  force  is  needed,  or  the 
thread  might  cut  through  the  tissues.  This  force  is  ottered  in  the 
species  of  fork  represented  in  Fig.  53,  which  is  put  as  a  fulcrum 
under  the  thread  at  its  point  of  exit,  and  made  to  sustain  and 
draw  it  throus-h. 


Fig.  51. 


Figs.  52,  53,  54. 


i     F 


Twisting  the  sutures. 


Fulcrum  for  supporting  wire  while  it  is 
twisted.  Fork  with  blunt  points  to  aid  the 
passage  of  sutures.  Hook  for  engaging 
needle. 


A  bit  of  silver  wire  about  twelve  inches  long  is  attached,  by 
bending  its  extremity,  to  the  first  silk  suture,  and  by  the  use  of 
the  fork  just  mentioned,  the  silk  thread  is  drawn  through  so  as  to 
make  the  wire  replace  it.  The  silk  is  then  cut  off,  the  silver 
suture  put  aside,  and  the  operator  proceeds  to  replace  each  silk 
thread  in  the  same  way.  This  being  accomplished,  the  instru- 
ments are  then  changed  in  order  to  effect  the  twisting  of  the 
sutures. 

The  ends  of  the  silver  sutures  being  drawn  together  by  the 
fingers,  and  the  edges  of  the  wound  carefully  approximated,  each 
thread  is  slightly  twisted  so  as  to  keep  the  whole  in  apposition. 
Then  the  ends  of  the  first  suture  are  seized  in  the  bite  of  the 
forceps,  Fig.  51,  slipped  into  the  fulcrum.  Fig.  52,  and  torsion  is 
made  so  as  to  close  the  wound  completely  at  this  point.  In  this 
way  the  sutures  are,  one  after  the  other,  twisted,  care  being  taken 
not  to  carry  the  torsion  so  far  as  to  strangulate  the  tissues  engaged 


198 


FISTULA    OF    THE    FEMALE    GENITAL    ORGAISTS. 


in  the  constricting  loop.  Each  suture  is  then  clipped  by  a  pair  of 
scissors,  about  half  an  inch  from  the  edge  of  the  fistula,  and  by 
means  of  forceps  pressed  flat  against  the  vaginal  wall  so  as  not  to 
wound  the  opposite  surface. 

The  bladder  should  then  be  syringed  out  to  remove  all  blood 
which  may  have  accumulated  there ;  for  if  a  large  clot  should  be 
retained  in  this  viscus,  it  may  cause  severe  vesical  tenesmus,  and 
smaller  ones  may  block  up  the  mouth  of  the  catheter,  which  is  to 
be  kept  in  place  permanently,  and  call  for  its  repeated  removal. 


Fiff.  55. 


1'  z' 


3     4 


-MrMv 


Sutures  twisted.     ("Wiel.and  and  Dubrisay.) 

The  patient  is  then  placed  in  bed  by  the  assistants,  an  opiate  is 
administered,  and  a  Sims's  sigmoid  catheter  is  passed  into  the 
bladder  and  left  there.  The  mouth  of  this  instrument  projects 
beyond  the  vulva,  so  that  under  it  a  small  china  dish  may  be 
placed,  which  will  receive  the  urine  as  it  passes  through. 

Fi?.  56. 


Sims's  sijrinoid  catheter. 


The  nurse  should  examine  the  catlieter  every  two  or  three  hours 
to  be  certain  of  its  perviousness,  and  to  remove  the  urine  which 
collects  in  the  receptacle  placed  under  it. 

Once  in  every  twenty-four  hours  the  vagina  should  be  syringed 
out  with  tepid  water,  or  with  this  and  wliite  castile  soap,  or  any 
similar  detergent ;  but  the  bladder  requires  no  further  washing 
than  that  mentioned,  except  in  cases  of  vesical  tenesmus.  The 
bowels  should  be  kept  constipated  by  opium.  The  diet  should  be 
governed  by  the  same  rules,  which  guide  us  in  the  management  of 
patients  under  other  surgical  operations.  It  should  be  nutritious 
and  unstimulating. 

In  from  eight  to  fourteen  days  the  sutures  should  be  removed. 


TREATMENT.  199 

Dr.  Sims  declares  that  "  it  is  unnecessary  to  allow  the  wires  to 
remain  longer  than  the  eighth  day ;"  but  others,  calculating  upon 
the  iiniocuousness  of  metallic  substances  in  the  tissues,  have  left 
them  longer.  In  two  of  Dr.  Schuppert's  cases  a  leaking  was  de- 
tected when  the  bladder  was  injected  on  the  sixth  and  seventh 
days,  which  had  disappeared  entirely  on  the  tAvelfth,  when  the 
sutures  were  removed  and  the  cure  was  found  complete. 

To  accomplish  the  removal  of  the  sutures,  the  twisted  end  of 
one  of  them  should  be  seized  by  a  pair  of  forceps  and  drawn 
upon  gently  until  the  edge  of  the  loop  emerges  from  the  tissues 
in  which  it  has  been  embedded.  Then  the  blade  of  a  jiair  of 
scissors  should  be  inserted  into  the  loop  and  one  side  cut,  after 
which  a  little  traction  will  remove  the  suture. 

An  examination  may  then,  with  great  caution,  be  instituted  to 
ascertain  whether  success  or  failure  has  attended  the  operation. 
A  visual  examination  will  generally  determine  this.  Should  there 
be  any  doubt,  the  bladder  may  be  filled  very  cautiously  -svith  tepid 
water  to  settle  the  question  as  to  the  entire  closure  of  the  fistula. 
Sometimes  one  operation  fails  to  cure,  although  it  diminishes  the 
size  of  the  fistula  very  much,  and  subsequent  operations  must  be 
resorted  to.  It  may  be  necessary  to  repeat  these  very  frequently 
before  success  is  attained. 

The  operation  of  Dr.  Sims  has  been  variously  altered  in  all  its 
steps,  so  that  now  the  number  of  modifications  is  quite  great,  so 
great,  indeed,  that  it  would  be  out  of  the  province  of  a  work  like 
this  to  mention  them  in  detail.  In  his  earlier  operations  Dr.  Sims 
employed  the  quill  suture,  which  he  called  the  clamp  suture,  but  a 
tendency  on  the  part  of  the  little  metallic  bars,  which  he  used  in 
place  of  quills,  to  produce  ulceration,  induced  him  to  resort  to  the 
interrupted  suture. 

Other  methods  have  been  successfully  employed  by  Bozeman, 
Agnew,  Baker  Brown,  Simpson,  Simon,  and  others.  For  fear  of 
being  uselessly  prolix,  I  shall  describe  but  one  of  these,  that  of 
Simon. 

Among  other  attempted  improvements,  Dr.  Startin  and  M. 
Matthieu,  of  Paris,  have  invented  hollow  needles,  through  which 
the  silver  threads  can  be  passed  without  first  passing  those  of  silk. 
Extended  experience  with  tubular  needles  leads  me  to  the  con- 
viction that  they  are  at  once  the  most  ingenious  and  worthless 
appliances  which  can  be  employed. 

Simon's  Operation. — No  one,  with  the  exception  of  Marion  Sims, 


200  FISTULiE    OF    THE    FEMALE    GENITAL    OEGANS. 

has  labored  more  earnestly,  or  achieved  more  for  this  operation 
than  Prof.  Gustav  ISiinon,  of  Heidelberg.  Succeeding  Dieffen- 
bach,  Wutzer,  and  Metzler,  who  had  themselves  accomplished  a 
great  deal  in  advancing  the  interests  of  the  operation  by  suture, 
he  steadily  labored  with  the  means  at  his  command,  and  even  be- 
fore he  became  acquainted  with  the  improvements  made  by  Sims, 
had  acquired  a  great  degree  of  skill  in  treating  vesico-vaginal 
fistulffi.  To  regard  him  as  an  imitator  would  be  unjust.  He  was 
without  question  a  coincident  discoverer. 

The  chief  features  of  Simon's  operation  are  these : 

1st.  He  repudiates  silver  wire  as  a  suture  superior  to  fine  silk. 

2d.  He  employs  an  exaggerated  lithotomy  position  in  place  of 
the  left  lateral  position. 

3d.  Instead  of  avoiding  the  mucous  membrane  of  the  bladder, 
he  intentionally  involves  it  in  his  abrasion. 

4th.  He  uses  no  stationary  catheter,  and  has  the  urine  drawn 
only  during  the  first  twenty-four  hours,  and  this  not  always. 

5th.  He  allows  the  bowels  to  be  evacuated  whenever  nature 
prompts  it,  and  does  not  diet  the  patient  nor  confine  her  to  bed. 
At  times  he  even  permits  outdoor  exercise  in  twenty-four  hours 
after  the  operation  in  favorable  cases. 

.  I  prefer  to  describe  his  procedure  as  for  as  possible  in  his  own 
words.  The  following  resume  of  his  method  is  made  up  from  his 
work  upon  "  The  Operation  for  A^esico- vaginal  Fistula,"  published 
in  1862. 

Position  of  Patient. — There  are  three  positions,  in  general  use,  for 
the  patient  in  operation  for  vesico-vaginal  fistula.  (1)  The  back, 
as  in  operation  for  stone.  (2)  The  knee-elbow;  and  (3),  Sims's 
position,  which  is  a  modification  of  the  latter.  "  I  use  neither  of 
these,  but  prefer  the  breech-back  yiosition  (Steiss-lilickenlage), 
which  has  all  the  advantages  of  those  mentioned,  without  their 
disadvantages.  It  consists  in  this,  that  the  patient,  lying  on  her 
back,  is  put  in  a  position  which  is  almost  exactly  similar  to  the 
knee-elbow  position.  The  breech  is  so  elevated  that  it  is  somewhat 
above  the  level  of  the  abdomen  and  breast.  The  thighs  are  bent 
back  towards  the  belly  and  the  sides  of  the  chest,  so  that  the 
breech  is  the  most  projecting  part.  The  legs  are  either  flexed  at 
the  knee,  or  extended  over  the  sides  of  the  chest.  The  vulva  is 
above  and  to  the  front.  The  head  is  supported  by  a  pillow.  If 
the  fistula  is  seated  very  high  in  the  vagina,  the  thigh  must  be 
drawn  as  far  as  possible  upwards ;  if  the  fistula  is,  however,  very 


TREATMENT. 


201 


near  the  vaginal  outlet,  we  are  not  obliged  to  elevate  the  breech 
so  much,  and  have  no  need,  therefore,  of  flexing  the  thigh  so 
forcibly.  I  have  called  this,  in  distinction  to  the  ordinary  back 
position,  the  "  Steiss-riickenlage  ;"  because  in  it  the  breech  (Steiss) 
is  the  most  projecting  part,  and  presents  itself  in  a  manner  very 
similar  to  the  breech  presentation  of  the  foetus. 

Fig.  57. 


Simon's  position  for  vesico-vaginal  fistula.     (Simon.) 


The  advantages  are : 

1st.  The  field  of  operation  is  clear,  we  are  not  obliged  to  operate 
between  the  thighs. 

2d.  The  assistance  can  all  be  given  from  the  side,  without  hinder- 
ing the  operator. 

3d,  It  allows  the  use  of  several  specula  and  the  side  retractors, 
to  expand  the  vagina  on  every  side. 

4th.  It  is  quite  as  well  borne  as  the  ordinary  back  position. 

5th.  It  admits  of  chloroform  narcosis 

If  the  fistula  can  be  brought  down  entirely  with  perfect  ease, 
I  bring  it  directly  to  light.  If,  however,  there  is  the  least  diificulty 
in  moving  it,  (as  in  the  majority  of  cases,)  I  operate  with  the  specula 
and  retractors,  with  the  fistula  in  sitd.  I  always  prove  this  by 
seizing  the  uterus  with  a  hooked-forceps  (Museux)  and  pulling  it 


202  FISTULA    OF    THE    FEMALE    GENITAL    ORGANS. 

gently  down,  before  I  operate  with  the  specula  and  levers.  I 
have  improved  Jobert's  method  of  seizing  the  cervix  with  the 
forceps  by  passing  two  threads  through  the  cervix,  thus  getting 
rid  of  an  instrument  which  is  very  much  in  the  way.  Sims  con- 
structed a  gutter  shaped  speculum  for  expanding  the  fistula,  which 
has  left  all  other  specula  in  the  back-ground.  He  used  four 
sizes.  It  is  shaped  liked  Neugebauer's  (1856),  except  that  instead 
of  ending  in  a  sharp  edge,  it  is  rounded  out  at  the  end.  I 
have  found  the  use  of  this  speculum  in  many  difficult  cases 
absolutely  insufficient,  and,  in  the  majority  of  cases,  it  only  an- 
swers the  purpose  by  the  aid  of  other  instruments  to  expand  the 
vagina.  I  use,  therefore,  not  this  speculum  alone,  but  also  a  flat- 
shaped  speculum  to  hold  up  the  other  vaginal  wall  and  also  side 
levers  (shaped  like  retractors),  to  hold  back  the  labia  and  sides  of 
the  vagina.  All  these  instruments  are  fixed  in  long  handles, 
curved  at  the  end,  in  order  to  get  them  out  of  the  way,  and  to 
give  the  assistant  a  firm  grasp. 

Always  use  the  widest  specula  possible,  Sims's  are  not  wide 
enough.     I  have  had  two  sizes  more  made. 

In  addition  to  these  I  often  use  long-handled  hooks  to  seize  the 
edges  of  the  fistula.  I  always  cut  the  cord-like  contractions  of  the 
vagina,  and  have  even  cut  the  vaginal  folds  which  were  in  the  way. 

Vivifying  the  Edges. 

All  operators  have  tried  to  give  a  large  surface  for  union  without 
enlarging  the  wound.  They  have  done  this  by  cutting  at  the 
expense  of  the  vagina,  leaving  the  edges  of  the  bladder  intact. 
According  to  my  observations  and  experience,  I  give  the  prefer- 
ence to  a  deep  funnel-shaped  incision  of  the  edges  of  the  fistula 
similar  to  the  incision  in  plastic  operations  in  any  other  part  of  the 
body.  The  incision  must  be  carried  to  the  healthy  tissue  and  all 
the  cicatricial  tissue  extirpated. 

It  extends  quite  through  the  walls  of  the  septum  to  the  vesical 
mucous  membrane,  and  sometimes  through  it. 

In  tliis  way  is  formed  a  steep  funnel-shaped  wound,  with  its  point 
in  the  bladder,  and  its  base  in  the  vagina,  and  its  edges  from  6  to 
8  Mm.  thick. 

Although  other  authors  wish  to  avoid  as  much  as  possible  the 
enlarging  of  this  defect,  it  is  exactly  here  only  where  union  can 
take  place,  by  first  intention,  that  I  strive  to  have  the  edges  as  free 
from  cicatricial  substance,  and  as  prone  to  union  as  possible;  and, 
even  in  the  largest  fistula,  I  do  not  refrain  from  this  repeated 


FRESHENING    THE    EDGES. 


203 


paring  off  the  edges,  even  to  making  the  defect  very  much  larger, 
until  the  union  is  accomplished.  And,  even  if  with  the  hest  pre- 
paration of  the  edges,  the  union  does  not  take  place,  and  we  meet 
with  entire  want  of  success,  the  woman  loses  no  more  urine  than 
before. 

Fiff.  58. 


Vivifying  fhe  edges  of  the  fistula.     (Simon.) 

Sometimes  I  cut  the  vesical  mucous  membrane,  and  sometimes 
avoid  it,  but  place  little  weight  on  that. 

The  advantages  claimed  are: 

Ist.  By  the  deep  funnel-shaped  incision  all  cicatricial  substance 
will  be  certainly  cleared  away. 

2d.  The  edges  are  more  prone  to  union,  as  they  unite  in  a  natural 
manner,  edge  to  edge,  and  not  with  a  flat  surface  on  the  same;  the 
nerves,  vessels,  etc.,  thus  ct^ntinue  on  in  the  normal  direction. 


204 


FISTUL.E    OF    THE    FEMALE    GEXITAL    ORGANS. 


3d.  The  very  wide  edge  is  unnecessary,  as  only  the  upper  edges 
unite  in  any  case. 

4th.  If  union  does  not  take  place  the  first  time,  a  second  attempt 
is  more  likely  to  succeed,  with  the  thick  edges,  than  where  with 
already  thin  edges,  these  must  be  bevelled  ofi"  still  more  and  made 
thinner. 

5th.  The  idea  that  catarrh  is  more  likely  to  follow  this  form  of 
incision  is  unfounded. 


Uniting  the  Edges  of  the  Wound. 

Method  of  Uniting. — There  have  been  a  great  number  of  methods 
of  bringing  the  edges  together;  all  of  which  accomplish  their  pur- 
pose, but  are  more  complicated  than  the  method  I  published  in 
1854,  which,  with  some  modification,  I  have  used  ever  since. 

Fijr.  59. 


J 


Sutures  in  position.     (Simon.) 


AFTER-TREATMENT.  205 

lu  order  to  meet  the  indication  for  uniting,  I  use  either  one  or 
two  rows  of  fine  silk  sutures  tied  in  the  ordinary  manner. 

In  large  fistulse,  where  a  great  degree  of  relaxation  is  necessary, 
in  order  to  bring  the  edges  into  exact  union,  I  use  my  so-called 
double  suture,  consisting  of  two  rows,  one  the  "relaxing,"  the  other 
the  "uniting,"  In  small,  or  in  slit-shaped  fistula,  I  use  only  one, 
the  uniting  row.  In  the  double  suture,  one  row,  placed  very  deep 
and  wide,  approaches  the  tissues  surrounding  the  fistula,  to  the  line 
of  union,  thus  relaxing  the  edges;  while  the  other,  placed  between 
the  stitches  of  the  first,  holds  firmly  the  edges,  and  thus  promotes 
the  most  exact  union.  When  only  one  is  used,  it  is  the  uniting 
row,  and  placed  in  the  same  manner  as  here  described.  Of  course, 
each  row  of  sutures  supplements  the  other  in  its  action. 

Both  rows  are  placed'  very  deep,  even,  in  many  cases,  through 
the  vesical  mucous  membrane.  They  thus  bring  the  edges  of  the 
wound,  in  their  whole  thickness,  in  the  closest  union,  and  withstand 
greater  traction  than  if  they  only  seized  a  part  of  the  edges.  The 
sutures  are  1-1^  lines  apart*.  The  point  of  entrance  of  the  threads 
is,  in  the  relaxing  suture,  some  distance  from  the  edge,  in  tlie  unit- 
ing, quite  near.  I  consider  it  of  very  little  importance,  whether  the 
suture  goes  through  the  vesical  mucous  membrane  or  not.  It  is 
only  necessary  to  be  careful  that  this  membrane  does  not  get 
between  the  edges  of  the  wound. 

After-  Treatment 

1st.  From  a  series  of  observations,  I  conclude  that  neither  on  the 
wound  nor  on  the  new  cicatrix  does  the  urine  have  any  injurious 
influence,  and  neither  hinders  the  union  by  primary  intention  nor 
loosens  a  once  formed  cicatrix. 

2d,  From  another  series  of  observations,  I  have  learned  that  the 
healing  is  not  interfered  with  by  a  degree  of  distention,  which 
could  come  in  a  normal  filling  of  the  bladder,  provided,  only,  that 
the  wound  is  perfectly  freshened  and  united. 

In  most  cases  the  permanent  retention  of  the  catheter  only  does 
harm. 

Each  of  these  deductions  is  drawn  from  a  number  of  appropriate 
cases. 

Upon  these  conclusions  then  is  based  my  after-treatment,  which 
up  to  the  removal  of  the  stitches  is  entirely  unimportant.  Those 
minute  directions,  the  carrying  out  of  which  is  so  tedious  both  for 
the  patient  and  physician,  are  all  laid  aside.     The  patient  is  per- 


206  FISTULA    OF    THE    FEMALE    GENITAL    ORGANS. 

niitted  to  take  any  position  she  chooses.  She  passes  her  water,  as 
soon  as  she  feels  the  need,  either  in  a  bed-pan,  or,  if  she  object  to 
that,  in  the  sitting  or  knee-elbow  position.  Only  in  a  few  cases, 
where  the  patient  is  not  in  a  condition  to  pass  water  spontaneously, 
is  the  catheter  used  every  three  or  four  hours.  On  the  fourth  or 
fifth  day  an  attempt  is  made  to  remove  the  stitches,  and  this  is 
repeated  on  the  following  days.  On  the  eighth  day,  the  patient  is 
allowed  to  leave  her  bed,  even  if  all  the  stitches  are  not  out. 

To  avoid  passages  from  the  bowels,  with  straining,  on  the  first 
eight  days,  a  fluid  discharge  is  recommended.  If  irritation  of  the 
bladder  ensue,  morphine,  one-eighth  grain  per  dose,  should  be 
given,  and  daily  warm  injections  into  the  vagina,  but  not  into  the 
bladder,  should  be  employed."^ 

Prof.  Simon^  reports  the  following  results:  "Of  118  fistulse  oc- 
curring in  105  patients,  there  were  104  fistulps  in  92  patients  cured 
completely  (a  later  cure  is  counted  in  under  the  first  category) ;  5 
fistulffi  in  5  patients  almost  entirely  closed ;  2  patients  with  3  fistulae 
discharged  as  incurable;  6  patients  died." 

In  the  description  of  Simon's  method  here  given,  the  words  of 
the  author  have  been  employed  as  much  as  possible. 

Elytroplasty. — This  operation  was  published  to  the  profession  by 
Jobert  de  Lamballe,^  in  1834,  and  was  subsequently  altered  and 
improved  by  Velpeau,  Gerdy,  and  Leroy  d'Etiolles.  It  consists  in 
dissecting  a  flap  from  one  buttock,  (Jobert,)  or  the  posterior  wall  of 
the  vagina,  (Velpeau  and  Leroy,)  and  fixing  it  by  sutures  into  the 
orifice  of  the  fistula,  the  borders  of  which  have  been  previously 
pared.  It  resembles  the  operations  of  rhinoplasty  performed  upon 
the  face,  but  is  unfortunately  even  more  diflicult  than  they,  and 
calls  for  such  great  manual  dexterity  as  to  preclude  its  frequent 
adoption.  Velpeau,  by  making  two  parallel,  longitudinal  incisions 
in  the  vagina,  dissected  up  the  intervening  tissue  and  stitched  it  to 
the  edges  of  the  fistula. 

Leroy  prolonged  these  incisions  to  the  vulva,  dissected  up  the 
intervening  flap,  and,  rolling  this  upon  itself,  applied  its  under  or 
bleeding  surface  against  the  fistula. 

Elytroplasty  is  still  employed  sometimes  where  great  destruction 
of  tissue  has  taken  place  at  the  base  of  the  bladder,  but  the  difiS- 


'  This  resume  has  been  prepared  from  Prof.  Simon's  work  by  Dr.  M.  D.  Mann. 

■■  Am.  .Tourn.  Obstet,  vol.  ii,  p.  241. 

3  Bull,  de  I'Acad.  de  M6d.  de  Paris,  t.  ii,  p.  145. 


CLOSURE    OF    THE    VAGINA.  207 

culties  and  uncertainties  attending  it,  together  with  the  fact  that 
more  simple  and  efficient  methods  for  dealing  with  this  class  of 
cases  are  at  command,  have  rendered  a  resort  to  it  very  rare. 

To  one  unaccustomed  to  the  treatment  of  fistulas,  it  would  appear 
that  the  larger  the  fistula  the  more  difficult  would  he  its  cure. 
This  is  not  so;  some  of  the  most  difficult  cases  will  be  found  to  he 
those  in  which  the  opening  is  so  small  as  to  he  discerned  with 
difficulty.  In  these  cases  I  would  strongly  recommend  the  follow- 
ing plan :  Introduce  into  the  bladder  a  large  steel  sound,  and  by  its 
extremity  make  the  fistula  to  project  towards  the  vagina.  Then 
cut  away  the  tissue  surrounding  the  fistula  so  as  to  let  the  sound 
pass  freely  into  the  vagina.  Sutures  may  then  be  passed,  and  the 
enlarged  fistula  cured. 

Closure  of  the  Vagina. 

This  procedure  is  resorted  to  in  despair  of  accomplishing  the 
cure  of  the  tistula,  and  in  the  hope  of  relieving  the  patient  from 
the  intolerable  annoyance  attendant  upon  an  involuntary  and  con- 
stant discharge  of  urine.  It  does  not,  of  course,  equal  in  efficiency 
closure  of  the  vesical  fistula,  since  it  involves  the  necessity  of  the 
urine  being  retained  in  the  vaginal  canal,  which  is  injured  by  its 
presence,  and  is  proposed  only  for  those  cases  in  which,  from  exten- 
sive destruction  of  tissue,  no  hope  of  closure  by  suture  or  elytro- 
plasty  can  be  entertained.  By  it  the  vagina  and  bladder  are  ren- 
dered a  common  receptacle  for  urine  and  menstrual  blood,  the  ordy 
advantage  gained  consisting  in  the  fact  that  they  may  be  retained 
and  discharged  at  will  through  the  urethra  which  remains  open. 

Closure  of  the  vagina  may  be  accomplished  by  two  operations, 
episiorrhaphy  and  obliteration  of  the  canal.  The  first,  which  con- 
sists in  paring  the  inner  surfaces  of  the  labia  majora  and  uniting 
them  by  sutures  so  as  to  cause  their  complete  adhesion,  originated 
with  Vidal  de  Cassis,  who  performed  it  in  1833.  The  operation  is 
exceedingly  simple  in  its  steps,  but  a  very  minute  opening  almost 
invariably  remains  just  under  the  meatus  through  which  a  little 
urine  exudes.  This  very  nearly  invalidates  the  success  of  the 
method,  for  even  a  slight  escape  renders  the  patient  uncomfort- 
able. 

The  second  consists  in  paring,  not  the  labia,  but  the  vaginal 
walls.  Strips  of  mucous  membrane  being  thus  taken  away,  the 
bleeding  surfaces  are  brought  in  contact  by  suture,  and  the  bladder 
is   kept   empty  by  a  catheter   until   union   has  occurred.      This 


208 


FISTULJE    OF    THE    FEMALE    GENITAL    ORGANS. 


procedure,  a  far  more  valuable  and  reliable  one  than  that  of  Vidal, 
was  first  performed  by  Simon,  who  has  applied  to  it  the  name  of 
"•  Kolpokleisis,"  or  cross  obliteration.  Prof.  Simon's  first  ofjeration 
was  performed  in  1855,  and  since  that  time  he  declares  that  it  has 
been  resorted  to  in  G-ermany  in  over  fifty  cases  with  complete 
success,  and  many  patients  sufiering  from  incontinence  of  urine 

Fig.  60. 


Obliteration  of  the  vngina.     (Simon.) 


due  to  great  loss  at  the  base  of  the  bladder  have  been  entirely  re- 
lieved by  it.  He  places  a  very  high  estimate  upon  the  operation, 
as  the  following  extract  from  a  published  letter  from  him  to  Dr. 
Bozeman  of  this  city  will  show: 

"  The  reason  why  I  have  proved  tlie  validity  of  my  claims  of  priority 
at  such  lengths,  is  simply  this,  that  in  my  opinion  kolpokleisis  is  the 
most  important  plastic  operation  which  in  the  last  decennia  has  origin- 


URINARY    FISTULA.  209 

ated  fi'om  one  single  man.  The  operation  of  vesico-vaginal  fistula  by 
uniting  the  borders  of  the  defect  is  indeed,  in  its  present  perfection  and 
precision,  a  much  more  important  acquisition  than  kolpokleisis,  and 
probabl)'  the  greatest  achievement  of  our  century  in  plastic  surgery; 
but  it  has  not  been  cariied  to  that  perfection  by  a  single  man,  but,  on 
the  contrary,  operators  of  all  nations  have  contributed  their  share  to  it. 
The  '  uranoplastie"  of  our  ingenious  countryman — von  Langenbeck — 
could  alone  be  placed  b}'  the  side  of  kolpokleisis,  as  far  as  the  safety  of 
the  performance  and  its  immediate  success  are  concerned.  It  would 
rank  higher  still  on  account  of  its  more  frequent  occurrence,  if  its  benetit 
for  the  voice  in  increasing  its  purity  could  be  secured  in  all  or  in  the 
majority  of  cases.  But  as  in  many  cases  this  result  is  not  obtained  at 
all  and  in  others  only  incompletely,  kolpokleisis  must  be  considered  the 
more  important  operation,  as  in  all  cases  it  fully  answers  its  purpose. 
This  operation,  which  1  invented  at  the  time  when  the  obliteration  of  the 
vulva,  proposed  by  Yidal,  proved  inefficacious  in  re-establishing  conti- 
nence of  urine,  has  already  been  performed  more  than  fifty  times  with 
complete  success.  Through  it  many  patients  with  incurable  defects  of 
the  bladder  have  been  freed  of  the  most  intolerable  suffering,  viz.,  the 
incontinence  of  urine.  I  have  myself  succeeded  in  eighteen  cases  in 
etfecting  perfect  obliteration,  and  every  German  surgeon  who  practises 
the  art  of  curing  vesico-vaginal  fistules,  has  recorded  one  or  more  suc- 
cessful cases  of  that  kind." 

In  his  earlier  operations.  Prof.  Simon  confined  this  procedure  to 
the  lower  section  of  the  vagina,  but  he  now  obliterates  the  canal 
just  below  the  loss  of  substance. 

Urinary  Fistulas  requiring  Special  Treatment. 

In  the  great  majority  of  instances  no  other  plan  of  treatment 
than  the  suture  is  necessary.  There  are,  however,  some  cases  of 
urinary  fistulce  in  whicli  the  application  of  the  suture  is  difficult,  or 
even  impossible.     These  will  now  engage  our  attention. 

Vesico-uterine  Fishdce. 

Jobert  first  pointed  out  the  proper  method  for  reaching  these. 
His  plan  is  not  at  present  employed,  but  that  now  regarded  as  most 
reliable  is  only  a  modification  of  it.  It  consists  in  slitting  up  the 
anterior  lip  of  the  uterus  until  the  fistula  is  reached,  vivifying  its 
edges,  and  passing  siitures  directly  through  the  cervix,  as  represented 
in  Fig.  61,  so  as  to  approximate  the  walls  of  the  cervix  and  the  lips 
of  the  fistula. 
14 


210 


FISTULA    OF    THE    FEMALE    GENITAL    OEGANS. 


Fiff.  61. 


In  case  the  fistulous  orifice  be  so  liigli  as  to 
be  considered  beyond  reach,  the  only  remain- 
ing resource  is  to  close  the  os  uteri  externum 
by  suture,  and  allow  menstruation  to  occur 
through  the  bladder. 

Vesico-utero-vaginal  Fistulce. 

For  these  the  plan  of  vivifying  the  anterior 
lip  of  the  OS,  and  thus  making  the  uterine 
tissue  subservient  to  closure  of  the  fistula,  is 
peculiarly  applicable.     The  operation,  repre- 
sented at  Fig.  62  is  similar  to  that  for  ordi- 
nary vesico-vaginal  fistula,  the  only  ditference 
being  that  one  lip  of  the  fistula  is  made  of  the 
vivified  cervix  uteri. 
In  case  the  anterior  lip  of  the  uterine  neck  be  so  completely 
destroyed  that  it  cannot  furnish  the  requisite  tissue  for  this  pur- 
pose, the  vagina  may  be  united  to  the  posterior  lip  so  as  to  throw 

Fig.  62. 


The  cervix  is  slit  to 
expose  the  fistula  above, 
and  sutures  are  passed. 


Anterior  lip  of  fistula  united  to  anterior  lip  of  cervix.     (Simon.) 


nie  cervix  into  the  bladder.  Menstruation  will  afterwards  occur 
into  that  viscus,  and  the  blood  thus  accumulating  be  discharged 
with  the  urine. 

Fistulce  ivith  Extensive  Destruction  of  the  Base  of  the  Bladder. 

It  has  already  been  mentioned  that  elytroplasty  and  kolpokleisis 
offer  resources  in  these  cases.     To  Dr.  Bozeman,  however,  we  are 


URINARY    FISTULiE. 


211 


Anterior  lip  of  fistula  niiitpd  to  poste- 
rior lip  of  cervix.     (Simou.) 


indebted  for  still  another  proce-  Fig-  63. 

dure,  the  first  step  of  which  con- 
sists in  dragging  the  uterus  down 
daily  for  weeks  before  the  opera- 
tion by  means  of  a  pair  of  forceps 
by  which  the  neck  is  seized.  In 
tliis  way  the  uterus  is  made  to 
approximate  the  vulva.  Then  one 
lip  of  the  cervix,  being  vivified,  is 
brought  into  contact  with  the  ex- 
tremity of  the  remains  of  the 
vesico-vaginal  septum,  and  firmly 
united  with  it  by  suture. 

To  facilitate  this  procedure,  the 
cervix  may  with  great  advantage 
be  slit  to  the  vaginal  junction  on 
each  side,  one-half  denuded,  drawn  forward  and  made  to  fill  the 
space  left  vacant  by  the  sloughing  of  the  vagina. 

In  addition  to  the  varieties  of  urinary  fistulfe  mentioned  here, 
certain  rare  instances  of  union  between  the  ureters  and  vagina  or 
uterus  have  been  recorded.  A  striking  example  of  uretero-uterine 
fistula  may  be  found  detailed  in  the  Dictionnaire  de  M(idecine,  vol. 
XXX,  by  M.  Berard.  It  is  not  only  interesting  in  itself,  but  as  dis- 
playing the  method  by  which  the  diagnosis  may  be  arrived  at  is 
worthy  of  special  mention.  Kegarding  it  at  first  as  a  vesico-uterine 
fistula,  from  the  fact  that  urine  was  discharged  from  the  uterus,  he 
arrived  at  a  different  diagnosis  from  these  facts: 

1st.  The  urine  flowed  steadily  from  the  cervix  when  the  bladder 
was  empty. 

2d.  The  urine  thus  flowing  was  limpid,  unlike  tliat  from  the 
bladder. 

3d.  The  patient  being  kept  seated  over  a  vessel  for  two  hours, 
so  as  to  preserve  all  the  urine  flowing  per  vaginam,  a  catheter  was 
passed  into  the  bladder  and  the  amount  removed  exactly  equalled 
that  which  had  escaped  vicariously. 

4th.  Injecting  the  bladder  with  fluid  colored  by  indigo,  the 
urine  passing  per  vaginam  remained  limpid. 

5th.  A  sound  being  passed  into  the  uterus  and  another  into  the 
bladder,  their  points  could  not  be  brought  into  contact. 

Uretero-uterine  fistula  is  by  no  means  common.  Dr.  Bozeman 
informs  me  that  he  has  rarely  seen  it,  and  not  one  instance  is 
mentioned  by  Dr.  Emmet  in  his  recent  work  upon  fistulse. 


212  FECAL    FISTULA. 

An  mterestino-  instance  of  union  between  the  ureter  and  vagina, 
uretero-vuo-inal  listula,  is  detailed  by  M.  Robert/  of  Paris,  as  the 
condition  remaining  after  an  operation  by  Dr.  Bozeman  at  the 
Hotel  Dieu, 

There  are  eccentric  and  rare  forms  of  fistula  which  I  have  not 
mentioned  in  my  enumeration.  For  example,  I  have  met  with  a 
case  of  vesico-abdominal  fistula.  Eight  days  after  the  operation 
of  ovariotomy,  about  one  pint  of  urine  began  to  pass  daily  through 
the  abdominal  opening,  the  lower  angle  of  which  had  been  kept 
open  for  washing  out  the  peritoneum.  That  the  fistula  was  vesical 
and  not  ureteral  was  proved  by  the  escape  of  colored  fluid  through 
the  abdominal  wound  when  injected  into  the  bladder.  This  pa- 
tient entirely  recovered,  and  the  fistula  healed  of  itself. 

Where  a  larger  extent  of  denuded  surface  is  required  than  can 
be  obtained  by  paring  the  edges  of  fistulre,  Langenbeck  and  Collis 
have  resorted  to  the  following  plan.  Splitting  the  edges  of  the 
fistula,  thoy  have  separated  the  two  flaps  thus  produced,  and 
bringing  the  opposing  raw  sui'faces  together,  have  secured  them 
by  suture. 


CHAPTER   XI. 


FECAL  FISTULA. 


Definition. — These  fistulfe,  which  are  much  less  frequently  met 
with  than  the  urinary,  consist  in  communications  established  be- 
tween the  vagina  or  vulva  and  some  part  of  the  intestinal  tract. 

Varieties. — They  may  l)e  recto-vaginal,  cntero-vaginal,  or  recto- 
labial  ;  the  first  being  the  most  common,  and  the  second  the  rarest 
of  the  varieties. 

Causes. — Tlie  causes  which  produce  them  are  almost  identical 
with  those  which  result  in  urinary  fistulse,  viz.  : 

'  Bozeman  on  Fistul?e,  N.  0.  Med.  and  Surg.  Journal,  March  and  May,  1860. 
Dr.  Bozeman  clearly  recognizes  this  form  of  fistula  as  a  result  of  the  ordinary 
operation  for  the  vesico-vaginal  variety,  explains  the  method  of  its  occurence,  and 
describes  his  "  usual  plan  for  overcoming  this  obstacle,"  when  he  has  'reason  to  fear 
its  occurrence  from  cutting  of  the  ureter." 


FECAL    FISTULA.  213 

Prolonged  pressure ; 
Direct  injury ; 
Ulceration  or  abscess. 

The  first  of  these  may  produce  them,  as  it  does  those  occurring 
on  the  anterior  vaginal  wall,  by  creating  an  intense  inllammation 
which  results  in  sloughing,  or  the  intensity  of  the  pressure  may 
be  so  great  as  rapidly  to  destroy  the  vitality  of  the  part.  Such 
pressure  is  most  frequently  the  result  of  difficult  parturition,  but 
in  rare  cases  it  may  arise  from  badly-fitting  pessaries  or  scybalous 
masses  in  the  rectum. 

Direct  injury  by  instruments  used  in  delivery,  or  others  em- 
ployed for  removal  of  impacted  feces,  may  evidently  produce  them. 

Ulceration  or  abscess  much  more  frequently  produces  fecal  than 
urinary  fistulre.  For  the  recto-vaginal  variety  stricture  of  the 
rectum  is  a  fruitful  source,  the  stricture  producing  a  retention  of 
fecal  matters  which  excites  ulceration  that  may  extend  to  the 
vaginal  canal.  An  abscess  between  the  vagina  and  rectum  may 
cause  a  communication  between  the  two,  or  burrowing  towards 
one  labium  may  oi:)en  there  and  connect  this  part  by  a  tract  with 
the  rectum.  In  the  same  manner  a  purulent  collection  has  been 
known  to  make  a  junction  between  the  caput  coli  and  vagina. 
Lastly,  syphilitic  and  cancerous  ulceration  may  open  a  channel 
between  the  intestinal  and  vaginal  canals. 

Symptoms. — The  most  prominent,  often  the  only  symptom  which 
will  attract  the  patient's  attention,  will  be  a  discharge  of  offensive 
gas  or  fecal  matter  by  the  vagina.  The  amount  which  escapes 
will  of  course  be  governed  by  the  size  of  the  fistula,  but  the  an- 
noyance dependent  upon  the  accident  will  not  be  so,  for  even  the 
smallest  quantity  will  be  sufficient  to  render  the  patient  utterly 
wretched  by  the  ofifensive  odor  to  which  it  gives  rise. 

Physical  Signs. — The  patient  being  placed  upon  the  back,  touch 
should  be  practised  upon  all  the  surface  of  the  vagina.  If  the 
fistula  be  one  of  any  magnitude,  this  will  at  once  discover  it.  If 
not,  careful  exploration  by  the  speculum  will  almost  always  do 
so.  Sims's  speculum  should  be  introduced  under  the  symphysis 
so  as  to  lift  the  anterior  wall  of  the  vagina  while  the  lateral  walls 
are  held  aside  by  spatulse.  Should  visual  exploration  not  reveal 
the  opening,  the  rectum  may  be  filled  with  tepid  water  colored 
with  cochineal  or  indigo,  and  its  escape  carefully  watched  for. 

Prognosis. — Fecal  fistulas  are  more  likely  to  be  spontaneously 
recovered  from  than  those  of  urinary  character,  from  the  fact  that 


214  FECAL    FISTULA. 

they  give  passage  to  gaseous  and  semi-fluid  excretions,  and  not  to 
an  irritating  fluid  which  is  constantly  dribbling  away  and  keeping 
the  tistulous  walls  from  uniting.  But  even  these  are  rarely  re- 
covered from  unless  surgical  aid  be  brought  to  their  relief. 

Fi"-.  G4. 


Exauiination  for  fecal  fistula. 

Treatment — Recto-vaginal  and  recto-labial  fistulse  should  always 
be  treated  by  suture. 

This  is  practised  upon  the  same  plan  as  that  which  is  followed 
in  vesico-vaginal  fistulse,  with  these  exceptions,  that  the  patient  is 
placed  in  the  position  adopted  in  operating  for  stone,  and  that  the 
speculum  is  so  inserted  as  to  elevate  the  anterior  instead  of  the 
posterior  vaginal  wall.  Before  operation,  the  sphincter  ani  muscle 
should  always  be  paralyzed  by  thorough  stretching  by  the  fingers, 
and  after  it  a  rectal  tube  should  be  retained,  unless  very  annoying 
to  the  patient.  After  the  operation,  too,  the  rectum,  which  should 
have  been  thoroughly  emptied  by  enema  before  it,  should  be  kept 
perfectly  quiet  by  opiates  for  ten  or  twelve  days.  When  evacu- 
ations are  first  permitted,  laxatives  should  be  employed  in  order 
to  avoid  tenesmus,  which  might  destroy  the  union  of  the  lips  of 
the  fistula. 

In  one  case  of  recto-vaginal  fistula  I  have  introduced  the  specu- 
lum into  the  rectum,  and  closed  the  fistula  on  the  rectal  surface. 
The  facility  with  which  the  operation  was  performed  was  surprising. 


SIMPLE    VAGINAL    FISTULA.  215 

Entero-Vaginal  Fistulas. 

Entero-  Vaginal  Fistula^  which  consists  in  a  fistulous  tract  between 
some  ]3art  of  the  intestinal  canal  above  the  rectum,  and  the  vagina, 
is  rare,  and  when  existing  should  be  looked  upon  as  an  artificial 
anus,  the  closure  of  which  would  be  attended  by  danger.  If  the 
opening  be  direct  and  there  be  no  tract  leading  from  one  canal  to 
the  other,  this  would  not  be  the  case,  but  if  a  tract  exist,  the 
closure  of  its  vaginal  extremity  would  probably  result  in  abscess 
excited  by  fecal  matters  passing  out  of  the  intestine. 

Simple  Vaginal  Fistulae. 

Definition. — Under  this  head  are  grouped  those  forms  of  fistulous 
connection  with  the  vagina  which  do  not  act  as  vicarious  outlets 
for  any  neighboring  organ,  as,  for  examj)le,  peritoneo-vaginal, 
perineo- vaginal,  and  blind  fistulse. 

Peritoneo-vaginal  Fistula  has  been  rarely  met  with.  When  it  does 
occur  it  is  attended  by  danger  of  descent  of  the  intestine  into  the 
vagina,  and  entrance  of  fluids  and  air  into  the  peritoneal  cavity. 
One  reason  for  its  rarity  is  probably  the  fact,  that,  no  excremen- 
titious  substance  passing  through  it,  it  very  generally  disappears 
without  becoming  chronic.  Should  it  not  do  so,  no  annoyance 
would  arise  from  its  existence,  and  it  would  be  susceptible  of  im- 
mediate cure  by  suture. 

Perinea-vaginal  Fistula  may  result  from  partial  closure  of  a  rup- 
tured perineum  leaving  a  small  orifice  near  the  sphincter  ani,  or 
from  penetration  of  the  presenting  part  of  the  foetus  through  the 
perineum.  It  may  be  readily  cured  by  incision,  ligature,  cauteri- 
zation, or  injection,  after  the  plan  just  pointed  out  in  connection 
with  focal  fistulje. 

Blind  vaginal  Fistulce  are  those  which  lead  to  a  purulent  collec- 
tion in  some  jmrt  of  the  pelvis.  They  will  be  fully  treated  of 
when  considering  pelvic  abscesses,  and  nothing  need  be  said  of 
them  here  further  than  to  mention  the  principles  upon  which 
their  treatment  rests :  1st,  dilatation  of  the  fistulous  tract  by  tents 
or  incision  ;  2d,  exerting  an  alterative  action  on  the  walls  of  the 
abscess  by  iodine,  iron,  nitrate  of  silver,  water,  etc.  etc. 


216  GENERAL    CONSIDEKATIOXS    UPON 


CHAPTEll    XII. 

GENERAL   CONSIDERATIONS   UPON   UTERINE  PATHOLOGY  ANU    TREATMENT. 

IsToTHiNG  more  decidedly  retards  the  progress  of  gynecology, 
lowers  it  as  a  special  study  in  the  eyes  of  the  sister  departments, 
and  fans  the  dying  flame  of  a  prejudice  with  which  it  has  been 
able  successfully  to  contend  only  during  the  past  half  century,  than 
the  unsettled  state  of  uterine  pathology.  In  general  medicine,  in 
surgery,  and  in  all  other  special  departments,  the  study  of  pathology 
is  made  the  keystone  of  the  arch  which  su})ports  them ;  and  ob- 
servers seem  willing  to  agree  as  to  fixed  principles  concerning  it. 
In  gynecology,  this  whole  subject  presents  the  melancholy  aspect 
of  uncertainty  and  dissension.  Many  of  its  votaries,  instead  of 
taking  broad  and  strong  views,  become  the  partisans  of  some  special 
dogma  or  theory,  which  is  warndy  attacked  by  others  who  hold 
some  view  equally  narrow,  incomprehcnsive,  and  exclusive. 

As  a  result  of  this  state  of  pathological  confusion  among  the 
leading  minds  devoted  to  the  department,  every  newdy-fledged 
specialist  feels  warranted  in  elaborating  and  maintaining  a  theory 
of  his  own ;  or,  in  attaching  himself  to  one  of  the  many  which 
present  tliemselves  for  his  choice. 

All  must  admit  that  to  this  department  to-day  as  many  able, 
zealous,  and  industrious  laborers  are  devoted,  as  to  any  other  in 
medicine.  Why  should  such  a  body  weaken  its  influence  by 
adherence  to  dissentient  and  partisan  views?  Why  is  one  impelled 
to  entertain  the  view  that  inflammation  of  the  parenchyma  plays 
the  irnportant  part  of  moving  cause  in  uterine  disorders ;  another 
that  displacements  of  the  uterus  do  so ;  another  that  the  chief 
trouble  consists  in  an  irritation  or  hyperesthesia  in  the  uterine 
nerves;  another  that  catarrhal  inflammation  of  the  uterine  mu- 
cous membrane  is  the  origin  of  most  of  its  disorders ;  while  still 
another  attributes  to  the  inefiicicnt  restoration  of  the  uterus  after 
the  structural  changes  due  to  utero-gestation,  the  most  important 
role  ?  To  one  who  calmly  and  dispassionately  considers  the  sub- 
ject, not  in  the  study,  but  by  the  bedside,  and  who  goes  to  it  with 
a  mind  free  from  prejudice,  and  eager  for  the  discovery  of  truth,  it 


UTEEINE  PATHOLOGY  AND  TEEATMENT.        217 

appears  to  me  that  it  must  in  time  become  evident  that  truth  lies 
not  in  any  one  of  these  theories,  but  is  to  be  found  to  a  certain 
extent  in  each.  JSTo  pathologist  claims  that  hepatic,  or  cardiac,  or 
renal  disease  has  always  the  same  pathological  origin ;  why  should 
any  one  expect  to  find  for  uterine  disorders  a  universal  pathogenic 
factor  ? 

At  no  period  in  modern  times  has  this  department  been  so 
favorably  and  resjiectfully  regarded  by  the  science  of  which  it  is  a 
part,  as  at  present.  E^ow,  then,  has  the  time  arrived  when  every 
one  of  its  well-wishers  should  strive  to  obliterate  all  factions  and 
parties,  to  free  it  from  dogmas  and  narrow  views,  and  place  it 
where  it  should  always  have  stood,  upon  the.  broad  platform  of  an 
enlightened  pathology. 

That  the  uterus  should  perform  its  functions  efficiently  and  nat- 
urally it  is  essential,  1st,  that  its  innervation  and  circulation 
should  be  normal ;  2d,  that  its  structure  should  be  unaltered  in 
character  and  proportions  ;  and  3d,  that  no  decided  and  perma- 
nent change  should  have  occurred  in  its  position.  An  abnormal 
state,  developing  in  connection  with  any  one  of  these  essential 
conditions,  may  derange  the  functional  powers  of  this  important 
viscus,  and  demonstrate  itself  by  symptoms  which  produce  greater 
or  less  discomfort  to  the  woman.  When,  as  very  often  happens, 
the  first  evil  produces  others,  until  at  last  all  three  conditions  are 
interfered  with,  the  gravity  of  the  symptoms  increases  with  simul- 
taneous increase  in  their  number  and  variety.  Sometimes  the 
first  link  in  the  chain  of  morbid  action  is  an  altered  condition  of 
the  nerves  governing  circulation,  some  general  or  local  condition 
reflecting  itself  upon  these  regulators  of  nutrition ;  as  a  conse- 
quence, an  afilux  of  blood  takes  place  to  the  uterine  mucous  mem- 
brane, and  its  vessels  become  distended,  and  in  time  dilated.  This 
lasts  for  a  variable  time,  when  the  second  link  is  furnislied  in  this 
manner :  an  excessive  degree  of  nutrition  is  supplied  to  tlie  sub- 
jacent connective  or  areolar  tissue  of  the  organ,  and  its  size  and 
weight  increase.  Then  the  third  link  rapidly  develops  itself. 
The  uterus  now  being  heavier  than  normal,  its  natural  and  hith- 
erto sufficient  supports  are  insufficient  for  its  maintenance  in 
position,  and  it  descends  in  the  pelvis,  so  as  sometimes  to  alter  the 
direction  of  its  axis,  and  protrude  between  the  labia  majora ;  at 
other  times  its  axis  is  not  changed  in  its  descent,  and  then  the 
cervix,  striking  against  the  curved  surface  of  the  sacrum,  is  bent 
forwards  so  as  to  oflfer  an  obstruction  to  the  escape  of  menstrual 
blood;  at  others,  the  fundus  falls  forwards,  laterally,  or  backwards, 


218  GENERAL    CONSIDERATIONS    UPON 

either  bending  upon  the  neck,  or  hy  its  displacement  forcing  this 
part  out  of  position  likewise.  Then  appear,  as  symptoms  of  this 
threefold  disturbance,  leucorrhoea,  backache,  dysmenorrhcea,  diffi- 
culty in  locomotion,  and  the  long  list  of  discomforts  to  which 
women  thus  aifected  are  liable. 

This,  however,  is  by  no  means  always  the  sequence  of  events. 
{Sometimes  the  uterus  enlarged  by  utero-gestation  does  not  return 
to  its  original  small  size,  but  remaining  large  and  heavy,  it  falls 
from  its  place  in  consequence,  and  tliis  disorder  of  position  reacts 
upon  the  other  two  conditions  which  I  have  stated  are  essential  to 
health — normal  innervation  and  circulation,  and  an  unaltered  state 
of  the  structure  of  the  organ. 

Again,  a  uterus  may  be  in  a  perfectly  normal  state  in  every  re- 
spect, when  suddenly  it  becomes  retroverted.  As  a  consequence, 
innervation  and  circulation  are  at  once  disturbed,  congestion 
occurs,  a  hypergenesis  of  tissue  gradually  takes  place,  and  thus 
what  was  originally  merely  a  displacement  becomes  a  condition 
of  congestion,  enlargement,  and  chronic  catarrh. 

Tlie  position  which  I  assume  with  reference  to  the  pathological 
series  which  may  result  in  confirmed  uterine  disease,  is  this:  that 
the  pelvic  organs  of  a  woman  who  has  liitherto  been  in  perfect 
health,  may  become  gradually  or  suddenly  diseased  by  one  of  the 
three  following  abnormal  developments  in  the  uterus:  1st,  disorder 
in  innervation  and  circulation  ;  2d,  change  in  quantity  of  connec- 
tive or  muscular  tissue;  3d,  change  in  position.  I  assume,  further- 
more, that  the  first  here  mentioned  being  the  primary  lesion,  the 
second  and  third  may  result  from  it ;  that  the  second  being  the 
primary  lesion,  (as  in  subinvolution  or  the  development  of  neo- 
plasms,) the  first  and  third  may  result  from  it ;  and  that  the  third 
primarily  showing  itself  in  a  perfectly  healthy  organ,  the  first  and 
second  may  be  its  consequences. 

Let  us  now  proceed  one  step  further.  Those  primary  pathological 
conditions  which  most  commonly  produce  disorder  in  the  three 
elements  which  I  have  mentioned,  may  be  said  to  constitute  the 
especial  factors  of  uterine  disease.     What  are  they  ? 

1st.  Catarrhal  inflammation  of  the  lining  membrane. 

2d.  Prolonged  congestion  of  uterine  tissues. 

3d.  Excessive  growth  of  connective  or  muscular  tissues. 
In  the  beginning  one  only  may  exist,  uterine  catarrh,  for  example ; 
m  time  this  may  induce  another,  congestion  in  the  parenchyma; 
and  still  later,  this  excessive  blood  supply  may  result  in  a  third. 


UTERINE  PATHOLOGY  AND  TREATMENT.        219 

liypergeiiesis  of  connective  tissue.  Whatever  then  tends  to  induce 
and  keep  up  any  one  of  these  three  morbid  states,  tends  directly  to 
the  establishment  of  confirmed  uterine  disease,  and  the  considera- 
tion of  this  point  brings  us  to  the  investigation  of  the  individual 
pathological  agencies  which  ordinarily  produce  such  a  result. 

1st.  In  the  very  large  majority  of  cases  of  uterine  disease,  the 
first  link  in  the  morbid  chain  is  subinvolution — which  produces  as 
direct  consequences,  passive  congestion,  hypersecretion  by  lining 
membrane,  menstrual  disorders,  displacements,  sterility,  and  inter- 
ference by  pressure  with  neighboring  organs. 

2d,  A  certain  number  of  cases  is  produced  by  disordered  uterine 
circulation  and  innervation,  the  results  of  displacement  of  the 
uterus,  either  as  a  whole  or  by  bending  of  itself  upon  its  axis. 
Such  displacement  or  distortion  induces  passive  congestion,  hyper- 
genesis  of  tissue,  dysmenorrhcea,  sterility,  and  endometritis. 

3d.  A  certain  number  of  cases  arises  from  primary  catarrhal 
inflammation  of  the  lining  membrane  of  the  uterus  itself.  This, 
commencing  as  an  entity,  results  in  hypergenesis  of  tissue,  displace- 
ments, menstrual  disorders,  and  sterility. 

4th.  In  a  number  of  cases  by  no  means  small,  the  circulation, 
innervation,  and  size  of  the  uterus  are  interfered  with  by  obstruc- 
tion to  the  escape  of  menstrual  blood.  Such  obstruction  distends 
the  uterine  cavity  by  the  imprisoned  menstrual  discharge,  inflames 
its  lining  membrane,  and  results  in  leucorrhcea,  dysmenorrhcea, 
hematocele,  and  flexions. 

5th.  In  some  cases  the  uterus  is,  by  sympathy  with  diseased 
ovaries,  kept  in  a  condition  of  exalted  innervation  and  deranged 
circulation,  which,  in  time,  eventuates  in  congestion  of  the  whole 
organ  and  hypersecretion  by  the  mucous  lining.  As  consequences 
of  these  states,  there  appear  as  symptoms  leucorrhcea,  menstrual 
disorders,  displacements,  sterility,  etc. 

6th.  The  development  of  benign  or  malignant  growths,  consist- 
itig  of  hyperplasia  of  one  or  more  of  the  uterine  elements,  often 
deranges  the  innervation,  circulation,  and  proportionate  weight  of 
the  uterus,  and  results  in  displacements,  sterility,  menstrual  disor- 
ders, leucorrhcea,  pelyic  pains,  mechanical  interference  with  sur- 
rounding organs,  etc. 

7th.  The  uterus,  although  not  primarily  affected,  may  become 
displaced  and  congested  from  interference  by  contracting  lymph, 
exuded  in  contact  with  it  and  over  its  surface,  as  a  consequence  of 
pelvic  peritonitis.  Such  displacement  and  congestion  may  result 
in  excessive  growth  of  tissue  and  endometritis. 


220  GENERAL    CONSIDERATIONS    UPON 

8th.  Disease  not  only  of  the  neck  but  of  the  body,  and  not  only     ■ ' 
of  the  mucous  membrane  but  of  the  proper  tissue  of  the  organ,  is 
often  induced  by  laceration  of  the  cervix  which  results  in  eversion 
and  the  exposure  of  a  large  and  vulnerable  surface  to  friction  and 
injury  during  coition  and  exercise. 

Let  the  pathological  state  which  establishes  the  disorder  be  what 
it  may,  after  it  has  continued  for  some  time  and  its  instrumentality 
has  resulted  in  fixed  disease,  the  following  symptoms  develop  as 
characteristic  of  such  disease:  leucorrhoea;  menstrual  disorders; 
pain  in  back,  loins,  and  pelvis;  sterility;  hysteria  or  nervous 
symptoms;  gastric,  intestinal,  and  vesical  derangements,  etc.  They 
are  confined  to  none,  but  in  time  mark  ail. 

With  these  facts  before  him,  the  student  may  well  ask,  how  any 
logical  mind  could  consent  to  adhere  to  an  exclusive  pathological 
doctrine,  ignoring  or  denying  others  of  unquestionable  importance 
and  significance?  It  has,  I  think,  been  done  by  confounding  cause 
and  effect.  He  whose  mind  is  hampered  by  the  theory  of  intlam- 
mation,  will  find  it  in  every  case  of  long  standing,  in  tlie  mucous 
membrane,  for  congestion  of  this  produces  hypersecretion ;  and  in 
the  parenchyma,  because  hypernutrition  in  this  part  has  resulted  in 
hypergenesis  of  tissue.  The  uterus  is  large,  tumefied,  secreting 
excessively,  and  tender  to  the  touch;  all  these  prove  for  him  "in- 
flammation" to  exist.  In  the  great  majority  of  cases  in  which  a 
diseased  uterus  is  examined  after  it  has  been  in  an  abnormal  con- 
dition for  a  long  time,  the  following  physical  signs  will  be  dis- 
covered : 

1st.  The  uterus  will  be  larger  than  normal. 

2d.  Catarrh  of  the  lining  membrane  will  exist. 

3d.  The  vaginal  face  of  the  cervix  will  be  in  a  granular  condition. 

4th.  The  uterus  will  be  displaced. 

5th.  The  ovaries  will  be  found  slightly  enlarged  and  sensitive. 

•Here  are  five  theories  oftering  themselves  for  adoption,  and  in  a 
conclave  of  five  consultants,  each  might  hold  an  unassailable 
ground,  and  each  might  possibly  be  right.  But,  as  no  one  has  the 
key  to  the  progressive  development  of  the  complex  condition,  no 
one  can  prove  himself  so.  According  to  my  observation,  the 
analysis  of  this  collection  of  morbid  states,  which  most  frequently 
furnishes  the  key  to  their  solution,  is  this : 

Involution  of  the  uterus  was  interfered  with  some  years  before, 
and  subinvolution  existed  for  a.  while,  and  gradually  resulted  in 


UTERINE  PATHOLOGY  AND  TEEATMENT.        221 

areolar  hyperplasia  •/  this  soon  resulted  in  displacement,  which 
impeded  venous  action ;  from  this,  a  uterine  catarrh  arose,  wliich 
excoriated  hy  its  discharge  the  vaginal  face  of  the  cervix;  from 
this  cause,  combined  with  friction,  granular  degeneration  took 
})lace;  and  the  irritation  transmitted  by  this  complication  of  irri- 
tating influences  created  enlargement  and  sensitiveness  of  the 
ovaries. 

I  say,  that,  according  to  my  experience,  the  most  common  factor 
of  this  series  is  subinvolution;  but  I  do  not  say  that  it  is  the 
universal  factor.  It  may  be  that  all  these  lesions  arose  from  con- 
gestion due  to  retroversion  which  has  been  neglected,  and  has 
long  prevented  free  venous  return.  Or,  perchance,  the  large 
granular  surface,  which  has  been  called  an  "inflammatory  ulcer," 
is  an  eversion  of  the  cervical  mucous  membrane  due  to  rupture  of 
the  cervix,  which  occurred  five  years  ago  in  parturition,  and  has 
kept  up  nervous  irritation  and  hyperaemia,  which  have  resulted  in 
all  these  "  signs  of  inflammation." 

Impressed  by  the  fact  that,  with  many  of  the  physical  and 
rational  signs  of  inflammation,  the  enlarged,  sensitive,  and  engorged 
uterus  is  not  inflamed  ;  one  party  has  endeavored  to  cut  the  gor- 
dian  knot  by  styling  the  anomalous  state  one  of  "  irritability." 
But  the  term  was  badly  chosen,  and  its  introduction  has  accom- 
plished more  of  confusion  than  of  simplification — nor  have  the 
profession  generally  been  willing  to  accept  a  name  signalizing  the 
nervous  condition  alone  for  a  state  characterized  by  congestion, 
hypergenesis  of  tissue,  and  coincident,  probably  resulting,  nervous 
exaltation. 

But,  it  may  be  asked,  is  not  this  condition  of  enlargement  of  the 
uterus  after  all  a  state  of  inflammation,  of  chronic  metritis,  how- 
ever it  may  have  arisen  ?  I  answer,  no  more  a  condition  of  chronic 
inflammation  than  is  the  enlargement  of  the  tonsils  which  lasts  for 
years  in  children  ;  or  than  the  tender,  enlarged  spleen,  the  ague 
cake  of  malarial  poisoning;  or  than  the  enlarged  testicle  of  syphilis. 
I  do  not  deny  the  name  and  character  of  inflammation  to  suppura- 
tive tonsillitis  or  quinsy,  to  the  orchitis  of  gonorrhoea  or  even  to 
that  very  rare  disease  splenitis,  which  sometimes  ends  in  suppura- 
tion. Let  the  unprejudiced  reader  reply  to  this  question  from 
his  own  observation:  does  the  state  of  the  uterus  whicli  we  are 


'  Hypertrophy  signifies  excessive  growth  or  enlargement  of  a  tissue  already  ex- 
isting :  hyperplasia  signifies  the  development  of  new  tissue. 


222  GENERAL    CONSIDERATIONS    UPON 

considerina;  most  resemble  the  former  or  the  latter  of  these  patho- 
logical states?     I  cannot  doubt  his  reply. 

These  remarks  apply  not  only  to  the  partisan  of  the  dogma  of 
inflammation,  but  to  those  of  all  the  others  which  have  been 
adopted.  He  who  wishes  to  sustain  his  views  and  his  party  by 
finding  displacement  will  almost  always  do  so,  for  a  heavy  uterus, 
which  was  in  normal  position  in  the  beginning,  generally  falls  from 
its  place  in  time  ;  he  who  looks  for  uterine  catarrh  will  likewise  be 
gratified,  for  a  congested  mucous  membrane  always  gives  forth 
an  excessive  secretion ;  and  even  he  who  will  be  satisfied  with 
nothing  but  ovarian  disease  will  often  be  able  to  sustain  liis  theory, 
for  chronic  uterine  disorder  is  very  apt  to  affect  in  time  these 
organs,  which  are  so  intimately  in  sympathy  with  the  uterus. 

Prognosis  in  Uterine  Affections. — There  is  no  organ  of  the  body 
the  diseases  of  which  offer  greater  dififtculties  in  prognosis  than 
those  of  the  uterus.  So  much  depends  upon  the  habits  of  the 
patient,  the  injurious  influences  to  which  she  is  exposed,  and  the 
faithfulness  with  which  she  follows  out  the  directions  of  the  phy- 
sician, that  often  very  little  can  be  predicted,  very  little  promised 
with  any  certainty.  The  error  into  which  the  incautious  practi- 
tioner is  most  likely  to  fall  is  that  of  predicting  a  cure  at  too  early 
a  period,  and  fixing  some  definite  time  for  its  accomplishment. 
The  patient  may  declare  that  she  and  her  friends  will  be  satisfied 
even  if  the  limit  be  fixed  not  by  months  but  by  3'ears,  nevertheless 
she  is  desirous  of  knowing  when  she  may  confidently  expect  a 
cure.  Tlie  answer  to  this  question,  not  in  the  lesser  interest  of 
the  practitioner,  but  in  the  greater  one  of  the  patient,  must  often 
be,  that  no  such  time  can  possibly  be  determined  upon.  In  some 
cases  it  becomes  necessary  to  state  further  that  not  only  is  the  time 
but  the  certainty  of  complete  cure  doubtful ;  that  local  treatment 
will  cause  pain,  may  result  in  danger,  and  may  absolutely  aggra- 
vate the  existing  symptoms. 

Another  point  which  influences  prognosis  is  this:  in  the  man- 
agement of  uterine  diseases  it  is  of  primary  importance  that  the 
practitioner  should  enlist  the  interest  and  co-operation  of  his 
patient.  Should  she  be  apathetic  with  regard  to  the  result,  or  even 
having  begun  treatment  with  enthusiasm,  become  disaffected  from 
any  cause,  his  duties  will  probably  prove  irksome,  annoying,  and 
fruitless.  For  this  reason  he  should  be  cautious  in  urging  with  too 
great  earnestness  the  adoption  of  local  treatment. 

In  view  of  this  and  the  additional  fact  that  treatment  may  ex- 
tend over  months,  before  a  cure  is  affected,  the  physician  should 


UTERINE  PATHOLOGY  AND  TREATMENT. 


223 


avoid  all  resources  which  by  their  uncleanliness  or  disagreeable 
nature  may  disgust  a  refined  patient,  or  make  her  rather  willing  to 
bear  her  disease  than  the  means  adopted  for  its  cure.  If  such 
means  will  be  very  likely  to  give  relief,  they  should  of  course  be 
employed ;  but  if,  as  is  the  case  with  many  of  them,  their  efficacy 
be  extremely  doubtful,  they  should  not  be  insisted  upon.  For 
example,  if  a  lively,  fastidious  lady  were  called  upon,  for  the  relief 
of  an  endometritis  which  is  not  in  itself  very  annoying,  to  forego 
society  and  spend  most  of  her  time  in  bed ;  to  fill  the  vagina  daily 
with  a  semi-solid  mass  of  powdered  linseed  after  the  method  of 
Melier ;  to  rub  mercurial  ointment  over  the  hypoo;astrium,  and 
have  a  weekly  application  of  leeches  around  the  anus,  she  would 
probably  in  time  get  tired  of  the  treatment,  and  lapse  into  the 
very  state  of  apathy  to  which  I  have  alluded. 

There  is  one  class  of  cases  in  dealing  with  which  I  should 
especially  recommend  that  perfect  frankness  be  observed.  It  may 
be  represented  by  a  patient  who  has  been  persuaded  by  husband, 
mother,  or  friends,  contrary  to  her  wishes,  to  submit  to  treatment. 
She  utterly  repels  the  course  to  be  adopted,  is  sure  that  it  will  do 

Fiff.  65. 


A  represents  the  dividing  line  between  body  and  cervix. 

tier  no  good,  is  unwilling  to  fulfil  the  directions  left  her  for  daily 
guidance,  but  yields,  under  the  assurance  of  her  advisers  that  the 
treatment  will  be  free  from  discomfort,  give  no  pain,  and  Avill 
surely  cure  her  in  a  few  weeks.     The  physician,  for  the  sake  both 


224  GENERAL    CONSIDERATIONS    UPON 

of  his  patient  and  himself,  should  avoid  joining  in  this  deception. 
Stating  the  facts  fully  to  her,  telling  her  of  the  danger  which  neg- 
lect will  involve,  and  of  her  duty  under  the  circumstances,  he 
should  ai)peal  to  her  reason,  and  decline  to  take  charge  of  her  case 
until  she  really  desires  his  services. 

There  is  a  general  rule  which  I  have  kept  before  me  as  a  guide 
to  proo;nosis,  and  which  has  so  rarely  failed  me  that  I  urge  it  upon 
the  attention  of  the  reader.  If  the  disease  atiect  that  part  of  the 
uterus  below  a  line  running  across  it  at  the  junction  of  the  neck 
and  the  body,  it  matters  not  how  grave  the  aiiection,  either  of 
mucous  or  parenchymatous  tissue,  if  it  be  not  of  malignant  type, 
a  prospect  of  cure  may  be  held  out.  Should  the  morbid  action 
exist  above  this  line,  even  if  it  present  no  features  of  special 
gravity,  the  physician  should  be  cautious  in  his  promises  of  cure, 
and  fix  no  limit  as  to  time.  It  is  true  that  recent  cases,  and  some- 
times even  old  ones,  of  corporeal  endometritis  may  be  cured  ;  but 
in  those  which  are  recent,  cure  is  always  very  difficult,  and  in  those 
which  are  chronic  often  impossible. 

Reasons  for  the  Frequency  of  Failure  in  the  Treatment  of  Uterine 
Diseases. — That  some  uterine  aftections  of  non-malignant  type  are 
incurable  cannot  be  denied  ;  but  even  jmtting  these  out  of  con- 
sideration, the  fact  is  notorious  that  the  local  treatment  of  these 
diseases  is  not  as  successful  in  its  results  as  we  could  wish.  I  now 
propose  an  investigation  into  the  causes  of  this  want  of  success. 
It  appears  to  me  that  the  most  apparent  and  most  constant  of  them 
may  thus  be  summed  up : 

Imperfect  diagnosis; 

Erroneous  prognosis ; 

Inefficient  or  inappropriate  therapeutics; 

Inattention  to  general  management. 

Im-perfect  Diagnosis. — It  is  not  rare  to  meet  Avith  instances  in 
which  physicians  have,  for  months,  treated  cases  of  uterine  disease 
concerning  the  nature  of  which  they  not  only  did  not  have  a 
correct  theory,  but  had  no  theory  at  all.  Under  these  circum- 
stances the  most  general  practice  is  to  pass,  about  once  a  week,  a 
solid  stick  of  nitrate  of  silver  up  to  the  os  internum,  not  to  cure 
cervical  endometritis,  for  that  has  never  been  suspected,  but  to 
do  the  best  one  can  in  the  way  of  treatment,  when  he.  does  not 
know  the  nature  of  the  disease  which  he  treats.  I  have  no  incli- 
nation to  attribute  this  always  to  any  intentional  laxity  of  morale, 
but  rather  to  indecision  and  aversion  to  creatino-  a  disao-reeable 


UTEEINE  PATHOLOGY  AND  TREATMENT         225 

issue  with  the  patient.  It  is,  however,  impossible  to  deny  the  fact 
that  such  a  course  will  sometimes  be  pursued  bj  those  who,  in  the 
case  of  a  diseased  eye  or  inflamed  knee-joint,  would  not  hesitate 
to  confess,  with  the  utmost  frankness,  their  uncertainty  and  need 
of  assistance.  With  uterine,  as  with  all  other  diseases,  the  diag- 
nosis nmst  be  properly  made  before  treatment  can  prove  curative ; 
and  in  this  field  of  practice,  fully  as  much  as  in  others,  honesty 
and  sincerity  should  guide  the  practitioner.  He  who  practises 
deception  here,  is  surely  no  less  culpable,  although  far  more  likely 
to  escape  detection,  than  the  charlatan  who  makes  it  a  rule  of  life. 

Erroneous  Prognosis. — Even  if  the  diagnosis  and  treatment  be 
correct,  an  erroneous  prognosis  as  to  time  of  cure  may  so  sap  the 
confidence  of  the  patient  as  to  send  her  to  other  counsel.  And 
now  she  may  run  the  gauntlet  of  theories  and  therapeutics.  Her 
first  attendant  having  recognized  endometritis  with  resulting  dis- 
placement, the  second  may  treat  the  displacement  alone,  as  the 
origin  of  her  symptoms.  Passing  into  the  hands  of  a  third,  she 
may  be  told  that  to  check  her  profuse  leucorrhoea  would  be  to  cure 
her  disease,  which  the  fourth  might  contradict,  with  the  assertion 
that  the  uterine  disorder  was  only  a  complication  of  ovaritis,  which 
was  the  fountain  of  all  her  difficulties. 

Ineffi^cient  or  Inapjyropriate  Therapeutics  may  cause  failure  in  cure 
even  when  a  proper  diagnosis  and  prognosis  have  been  made.  At 
times  a  course  of  local  alteratives  may  be  persevered  in  when 
the  disease  demands  more  general  treatment.  At  others  it  is 
necessary  to  carry  local  applications  up  into  the  cavity  of  the  body, 
and  not  of  the  neck  alone ;  and  at  others  still,  to  perform  a  .trifling 
surgical  operation  to  remove  a  difiiculty  which,  unless  removed, 
may  keep  up  the  disease  indefinitely. 

The  best  results  in  the  management  of  these  affections  will  not 
follow  a  direct  resort  to  treatment  of  the  most  prominent  existing 
disease,  but  will  very  often  be  obtained  by  removal  of  its  cause, 
or  the  alleviation  of  its  complications.  Let  me  make  my  meaning 
clear  by  some  examples.  The  physician  examines  and  finds 
endometritis  to  exist  with  its  usual  symptoms,  leucorrhoea,  pain, 
menstrual  disorders,  etc.  This  aftection  may  l)e  the  result  of  an 
antecedent  displacement.  If  it  be  so,  replacing  and  retaining  in 
position  the  displaced  organ  should  be  the  first  steji  in  treatment, 
as  it  was  the  first  step  in  diseased  action.  Causa  non  suhlata  tolUtur 
non  effcefus,  is  as  true  as  the  converse  proposition.  Again,  a 
patient  has  menorrhagia  and  prolonged  menstruation  with  a  long, 
contracted  cervix  uteri.  Obstruction  to  the  ready  escape  of  men- 
16 


226  GENERAL    CONSIDERATIONS    UPON 

strual  blood  often  so  alters  the  lining  membrane  of  the  body  of 
the  uterus  as  to  create  these  disorders.  If  the  physician  treat  the 
symptom,  he  will  surely  fail  in  curing  it,  while  success  will  attend 
his  eftbrts  if  he  remove  the  obstruction  which  prevents  the  uterus 
from  emptying  itself. 

So  also  with  the  complications  which  are  excited  by  uterine 
disorders.  A  patient  is  aftected  by  cervical  endometritis  that 
in  time  produces  hyperj^lasia,  which  by  increasing  uterine  weight 
displaces  the  uterus.  That  organ  lying  upon  the  floor  of  the 
pelvis  is  injured  by  locomotion  and  coition,  its  lower  segment  is 
bathed  in  purulent  leucorrhoea,  and  great  pelvic  pain  annoys  and 
harasses  the  patient.  If  the  practitioner  expect  to  cure  her,  let 
him  at  the  same  time  that  he  treats  the  primary  disease,  the  endo- 
metritis, relieve  a  set  of  complications  which,  uidess  removed,  will 
cause  repeated  relapses  as  often  as  he  approaches  the  accomplish- 
ment of  his  end. 

One  more  example  may  be  cited  before  concluding  these  remarks. 
A  displacement  of  the  uterus  exists,  and  the  practitioner  knows 
that  it  has  been  due  to  one  of  two  influences,  either  increase  of 
uterine  weight,  or  loss  of  uterine  support.  "Which  was  primary 
he  cannot  determine,  for  at  the  time  of  his  examination  both  exist. 
To  efl:cct  a  cure  it  would  be  the  part  of  wisdom  not  to  limit  treat- 
ment to  one,  but  simultaneously  to  treat  both  by  giving  artificial 
support,  and  diminishing  uterine  weight.  Without  being  able  to 
say  which  is  the  original  disease  and  which  the  complication,  he 
should  endeavor  to  relieve  both  at  the  same  time.  And  here, 
unfortunately,  the  patient  is  liable  to  come  in  contact  with  the 
personal  prejudice  of  her  attendant ;  lie  does  not  approve  of  pessa- 
ries. Why  ?  Because  he  has  seen  them  do  great  damage  !  Yet 
he  does  approve  of  splints,  of  the  catheter,  of  anresthesia,  and  of 
opium  1  Very  likely  he  has  not  given  an  hour  to  the  investigation 
of  this  important  subject  in  his  whole  professional  career.  How 
often  do  patients  come  to  those  specially  treating  these  diseases, 
after  years  of  treatment  from  such  prejudiced  practitioners,  with 
anteversion,  retroversion,  or  slight  prolapse,  and,  obtaining  imme- 
diate relief,  ask  in  surprise  the  significant  question,  why  was  this 
not  done  lono;  a^o  ? 

Inattention  to  General  ManagemerH  and  Hi/giene. — The  statement 
which  we  often  meet  with,  that  the  majority  of  the  cases  of  uterine 
disease  require  no  local  treatment  whatever,  is  a  fallacy,  based 
either  upon  strong  prejudice  against  one  of  the  most  important 
modern  improvements  in  medicine,  or  upon  want  of  experience  in 


UTERINE  PATHOLOGY  AND  TREATMENT.        227 

such  cases.  But  too  much  stress  cannot  be  laid  upon  the  advan- 
tages to  be  derived  from  constitutional  treatment  and  the  general 
management  of  these  cases.  We  too  often  fail  to  insist  upon  rest, 
cessation  of  marital  intercourse,  quietude  after  applications  to  the 
uterus,  and  other  points,  a  neglect  of  which  may  exert  a  powerful 
influence  for  evil,  and  frustrate  the  effects  of  all  that  is  done  by 
local  means. 

Astruc  begins  his  directions  for  treating  uterine  ulcers  by  ad- 
vising— 

"  To  charge  the  patient  to  abstain  from  all  kinds  of  exorcise,  and  to 
keep  constantly  laid  down  on  a  long  seat. 

"  It  is  for  the  same  reason  fit,  in  the  case  of  a  married  woman,  that 
she  should  lie  separately  from  her  husband. 

"  They  should  for  the  same  reason  guard  against  all  the  passions  of 
the  mind  that  may  agitate  it,  as  grief,  uneasiness,  and  anger,  etc." 

This  advice,  given  over  a  century  ago,  is  often  neglected  to-day, 
and  too  much  reliance  placed  upon  local  means,  and  u[>on  them 
alone.  Every  one  who  has  had  experience  in  the  treatment  of 
these  disorders  must  have  been  struck  with  surprise  at  the  won- 
derful improvement  exerted  upon  cases,  which  have  long  resisted 
local  means,  by  a  sea-voyage,  a  visit  to  a  watering-place,  a  course 
of  sea-bathing,  or  a  few  months  passed  in  the  country.  IS^ot  only 
is  this  improvement  manifest  in  the  general  state  of  the  patient ; 
it  shows  itself  locally,  also,  and  in  some  cases  com])lete  recovery 
may  be  thus  attained.  The  same  ftict  is  equally  noticeable  in  old 
ulcers  of  the  leg ;  local  means,  the  efficacy  of  which  in  such  cases, 
no  one  doubts,  having  failed  in  producing  good  results,  entire 
recovery  is  eft'ected  by  means,  such  as  those  alluded  to,  which  act 
upon  the  constitution. 

I  remember  having  had  this  very  decidedly  impressed  upon 
my  mind  by  the  following  case :  I  had  for  months  been  treating  a 
delicate  lady  for  marked  retroversion  with  cervical  endometritis 
and  hyperplasia,  the  results  of  an  old  subinvolution.  Suddenly  her 
friends  made  up  their  minds  to  visit  the  Holy  Land,  and  she  was 
eager  to  accompany  them,  and  applied  to  me,  not  for  permission, 
but  assent,  for  she  had  evidently  determined  to  go  before  consult- 
ing me.  A  great  part  of  the  journey  was  to  be  made  on  horseback 
at  a  very  slow  gait,  and  I  really  feared  that  she  would  be  made 
very  ill  by  it.  To  my  surprise,  however,  she  rapidly  improved, 
and  returned  to  this  country  better  than  she  had  been  for  years. 
And  yet  upon  examination  I  found  the  uterus  still  out  of  position, 


228  UTERINE    PATHOLOGY    AND    TREATMENT. 

and  granular  degeneration  of  the  cervix  still  existing,  though  much 
improved. 

It  should  not  be  forgotten  by  the  gynecologist  that  chronic  local 
disease  is  often  caused  by  a  general  depreciation  of  the  system.  In 
some  cases  the  lungs  undergo  chronic  pneumonic  consolidation, 
which  often  goes  on  to  phthisis ;  in  others,  chronic  corneitis  or 
granular  lids  occur;  while,  in  others  still,  cervical  endometritis 
marks  the  altered  constitutional  condition.  When  such  a  result 
takes  place,  the  two  states  continue  to  react  one  upon  the  other. 
The  depraved  system  increases  the  local  disorder  to  which  it  has 
given  rise,  and  the  irritation,  kept  up  by  the  latter,  aggravates  the 
degree  of  the  former.  This  being  true,  it  would  evidently  be 
irrational  to  treat  one  of  the  two  existing  pathological  conditions 
without  having  due  regard  to  the  other.  Some  cases  of  endome- 
tritis, liowever,  occur  in  women  who  are  apparently  in  good  health, 
and  are  usually  the  consequences  of  parturition  or  abortion.  But 
cervical,  and  even  corporeal  endometritis,  the  latter  of  which  may 
go  on  to  granular  degeneration,  will  generally  be  found  to  have 
engrafted  themselves  upon  a  depreciated  system. 

The  following  case  is  illustrative  of  this  view.  Dr.  Alfred  E. 
M.  Purdy  brought  to  my  office,  for  examination,  a  patient  who 
had  two  uteri  and  two  distinct  vagin?e.  As  I  proceeded  to  ex- 
amine, he  stated  that  the  right  uterus  was  affected  by  granular 
degeneration.  I  discovered,  however,  that  both  were  thus  dis- 
eased. Dr.  Purdy  had  not  examined  for  some  weeks,  and,  during 
this  period,  the  general  state  which  had  produced  disease  in  one 
uterus  had  effected  the  same  change  in  the  other.  It  may  with 
justice  be  objected  that  both  may  have  been  produced  by  a  local 
cause.  None  such  could  be  discovered,  the  patient  having  been 
exposed  to  no  local  influences  which  had  not  existed  for  years 
previously. 


ACUTE    ENDOMETRITIS.  229 


CHAPTER    XIII. 


ACUTE  ENDOMETRITIS. 


The  varieties  of  inflammation  of  the  lining  membrane  of  the 
uterus  may  be  clearly  expressed  in  the  following  manner: 

{  General. 
Acute     "I  Cervical. 
(  Corporeal. 


Endometritis  - 


General. 


Chronic  -!  Cervical. 
(  Corporeal. 

Synonyms. — Acute  endometritis  has  been  treated  of  under  the 
names  of  acute  uterine  leucorrhoea,  acute  uterine  catarrh,  acute 
internal  metritis. 

Frequency. — Acute  inflammation  of  the  lining  membrane  of  the 
uterus  is  a  condition  which  occurs  quite  frequently.  Often  run- 
ning a  rapid  course,  however,  and  ending  in  recovery  or  in  chronic 
disease,  it  passes  unrecognized  in  many  cases.  In  this  way  I 
would  explain  many  of  the  cases  of  suppressio  mensium  and  con- 
gestive dysmenorrhoea,  which  we  so  often  find  ending  in  chronic 
disease.  And  thus  also  would  I  account  for  the  profuse  and  pain- 
ful attacks  of  leucorrhoea  occurring  with  exanthematous  fevers, 
and  lasting  for  a  length  of  time  after  they  have  passed  off".  It  is 
very  generally  stated  that  acute  metritis  is  seldom  met  with  except 
as  a  sequel  of  parturition,  and  I  agree  in  the  statement  as  applying 
to  parenchymatous  inflammation,  but  it  does  not  apply  to  endo- 
metritis, which  often  proves  the  source  of  sudden  menstrual  dis- 
order and  the  cause  of  violent  leucorrhoea. 

Varieties. — The  morbid  process  may  aflfect  the  lining  membrane 
of  the  cervix  or  of  the  body  alone,  or  it  may  attack  the  whole  uterine 
mucous  tract,  its  selection  of  site  being  governed  by  its  cause. 
Thus,  that  form  which  immediately  follows  parturition  or  abor- 
tion or  results  from  gonorrhoea,  is  likely  either  to  aflfect  the  whole 
mucous  tract  or  the  cervical  canal  alone;  while  that  which  is  due 
to  sudden  checking  of  the  menstrual  flow  is  more  likely  to  be  con- 
fined to  the  body. 


280  ACUTE    ENDOMETRITIS. 

Causes. — The  causes  of  acute  endometritis  are  as  follows: 

Direct  injury; 

Cold  from  exposure  during  menstruation ; 

Constitutional  disease  of  septic  or  asthenic  character; 

Vaginitis,  specific  or  simple ; 

Evacuation  of  retained  menstrual  blood ; 

Excessive  venery ; 

Suppression  of  menstruation. 

Examples  of  direct  injuries  which  may  produce  acute  endome- 
tritis are  the  introduction  of  the  uterine  sound  or  the  intra-uterine 
pessai'y,  the  employment  of  tents  or  the  applications  of  chemical 
irritants,  surgical  operations,  and  intemperate  coitus. 

It  is,  probably,  in  some  instances,  through  the  instrumentality  of 
this  disease  that  those  cases  of  fatal  peritonitis  which  result  from 
tents,  sounds,  and  intra-uterine  pessaries  occur.  Inflammatory 
action  is  first  set  up  in  the  lining  membrane  of  the  uterus,  and 
thence  swiftly  passes  through  the  Fallopian  tubes  to  the  peritoneum. ' 

Specific  vaginitis  or  gonorrhoea  will  sometimes  pass  up  into  the 
cervix  and  body  of  the  uterus,  and  out  through  the  Fallopian 
tubes,  creating  pelvic  peritonitis  of  most  violent  character.  Even 
simple  vaginitis,  when  of  very  severe  form,  may  produce  endo- 
metritis, though  this  is  by  no  means  common. 

The  peculiar  blood  state,  attending  upon  and  forming  an  ele- 
ment of  measles,  scarlatina,  variola,  and  roseola,  and  its  influence 
on  all  the  mucous  linings  of  the  body,  will  sometimes  result  in 
general  endometritis,  and  the  hemic  condition  resulting  from 
phthisis  not  rarely  does  so.  Kiwisch  has  styled  this,  "  metastatic 
constitutional  catarrh." 

Exposure  to  cold  and  moisture,  great  mental  anxiety,  or  any 
other  influence  which  suddenly  checks  the  menstrual  flow,  not  in- 
frequently produces  this  disease.  At  the  moment  of  exposure  sup- 
pressio  mensium,  or  congestive  dysmenorrhoea,  may  take  place,  and 
from  that  time  endometritis  may  exist.  When  we  consider  that 
such  a  sudden  check  of  menstruation  will  sometimes  result  in 
hematocele  of  fatal  character,  it  is  certainly  not  to  be  wondered  at 
that  it  may  likewise  produce  the  disease  of  which  we  are  speaking. 

Excessive  venery,  even  where  no  violence  is  done  to  the  uterus, 
may  produce  it  by  the  prolongation  of  intense  congestion  of  the 
organ  kept  up  by  this  act. 

It  is  a  well  known  fact,  that,  when  menstrual  blood  is  retained 
for  a  long  time  in  utero  by  an  obstruction  in  the  vagina  or  at  its 
mouth,  by  an  imperforate  hymen,  for  example,  the  severance  of 


PHYSICAL    SIGNS.  2-Sl 

the  occluding  medium  and  admission  of  air  will  often  result  in 
endometritis  of  dangerous  and  even  fatal  character.  Such  cases 
appear  to  resemble  very  closely  the  septic  endometritis  which 
occurs  after  parturition,  and  constitutes  the  first  step  towards  sep- 
ticaemia and  peritonitis. 

Symptoms. — The  disease  demonstrates  its  presence  in  the  non- 
j)uerperal  uterus  without  any  very  violent  symptoms. 

Ordinarily  the  patient  complains  of  pain,  weight,  and  dragging 
in  the  pelvis ;  pain  in  the  back,  groins,  and  thighs ;  burning  and 
pricking  in  the  vagina,  and  vesical  and  rectal  tenesmus.  After 
four  or  five  days  there  is  usually  a  discharge  of  a  viscid  liquid, 
which  in  eight  or  ten  days  becomes  creamy,  purulent,  and  perhaps 
bloody ;  tympanites  and  sensitiveness  upon  pressure,  and  uterine 
tenesmus  or  "bearing-down  pains,"  show  themselves  in  severe 
cases,  and  at  times,  though  rarely,  there  is  active  diarrhoea  due  to 
reflex  irritation  of  the  rectal  nerves.  Should  the  fluid  discharged 
from  the  vagina  be  allowed  to  come  in  contact  with  the  skin  of  the 
vulva,  abdomen,  or  thighs,  an  intense  cutaneous  irritation  is  estab- 
lished, which  may  go  on  to  excoriation  and  the  development  of 
pruritus  of  aggravated  character.  In  two  cases  I  have  seen  prurigo 
thus  excited  which  spread  over  the  entire  body.  If  the  reaction 
of  this  purulent  discharge  be  examined  into,  it  will  sometimes  be 
found  to  be  acid  and  at  other  times  alkaline.  The  explanation  of 
the  fact  is  this:  the  discharge  from  the  uterus  is  alkaline  and  that 
from  the  vagina  acid.  If  the  irritating  uterine  fluid  have  estab- 
lished, as  it  very  generally  does,  vaginitis,  the  acid  secretion  from 
this  source  overcomes  the  alkalinity  of  that  from  the  other.  If,  on 
the  other  hand,  no  severe  vaginitis  exist,  the  discharge  from  the 
uterus  presents  its  ordinary  alkaline  features. 

Physical  Signs. — An  examination  by  touch  reveals  the  vagina 
hot  and  dry,  or  covered  by  the  discharge  noted  above.  The  os  uteri 
is  found  gaping,  the  cervix  swollen  and  very  sensitive  to  pressure, 
the  body  slightly  enlarged,  and  the  whole  organ  lower  than  normal 
in  the  pelvis.  Through  the  speculum  the  cervix  is  found  to  look 
swollen,  oedematous,  and  red,  and  from  the  pouting  os  pours  forth 
either  a  clear,  albuminous-looking  fluid,  muco-pus,  or  long  tenacious 
shreds  of  cervical  mucus.  All  explorations  of  the  uterus  should, 
as  a  rule,  be  avoided.  The  probe,  if  used  at  all,  should  be  employed 
with  the  greatest  caution,  and  never  unless  passed  through  the  specu- 
lum. The  sound  as  ordinarily  used  should  not  be  thought  of.  It 
will  discover  great  sensitiveness  throughout  the  uterine  cavity,  and 
the  slightest  touch  upon  the  fundus  will  cause  a  few  drops  of  blood 


232  ACUTE    ENDOMETRITIS. 

to  flow.  Indeed,  so  great  is  the  engorgement  that  even  the  intro- 
duction of  the  speculum  will  often  cause  blood  to  flow  from  the 
cervix. 

Bimanual  examination  will  discover  the  uterine  body  enlarged, 
and  tender  upon  pressure,  so  that  one  who  judged  hastily  and 
without  sufiicient  knowledge  of  the  subject,  would  be  very  apt  to 
diagnosticate  with  great  jiositivcness  acute  parenchymatous  me- 
tritis. There  can  be  no  doubt  that  many  of  the  reported  cases  of 
that  affection  have  been  nothing  more  than  instances  of  this  form 
of  endometritis. 

Differentiadon. — The  only  diseases  with  which  this  would  with 
any  probability  be  confounded,  are  periuterine  cellulitis,  pelvic 
peritonitis,  and  acute  vaginitis.  In  the  first  two  of  these,  consti- 
tutional disturbance  is  generally  more  marked  and  excessive  than 
in  this;  they  are  often  preceded  by  chill,  and  usually  by  more 
intense  febrile  action,  and  greater  elevation  of  temperature.  This, 
however,  is  not  universally  true.  The  last  is  very  generall}' 
attended  by  a  lesser  degree  of  general  disturbance.  ]^o  positive 
conclusion  can  usually  be  arrived  at  without  ph^'sical  exploration, 
which,  in  pelvic  inflammation,  will  discover  fixation  of  the  uterus, 
hardening  of  periuterine  tissue,  and  excessive  tenderness  when 
parts  other  than  the  uterus  are  compressed  by  conjoined  manipula- 
tion. It  will  generally  be  noticed  that  in  cellulitis  and  peritonitis 
there  is  no  great  increase  of  uterine  or  vaginal  discharge. 

Pathology. — In  its  first  stage  acute  endometritis  consists  in  an 
intense  and  active  hyperaemia  of  the  mucous  lining  of  the  uterus, 
which  is  red,  swollen,  (edematous  and  softened.  Its  surface  is 
spotted,  Scanzoni  declares,  from  congestion  of  the  capillary  net- 
work around  the  mouths  of  the  utricular  follicles.  When  the 
second  stage  has  set  in,  the  cavity  of  the  uterus  is  found  to  contain 
an  excess  of  mucus  or  creamy-looking  pus,  which  may  be  more  or 
less  mingled  with  blood.  If  the  cervix  be  involved  in  this  inflam- 
matory engorgement,  the  mucous  membrane  of  its  vaginal  portion 
participates  markedly,  as  an  examination  hy  the  speculum  will  prove. 

In  the  mucus  just  mentioned  the  microscope  reveals  the  presence 
of  thousands  of  cells  and  sometimes  entire  casts  of  the  utricular 
follicles. 

"Ordinarily,"  says  Scanzoni,^  "acute  catarrh  of  the  mucous 
membrane  of  the  uterus  is  accompanied  by  a  congestive  swelling 
of  the  muscular  substance  of  the  womb,  and  most  generally  it  is 


'  Diseases  of  Females,  American  ed.,  p.  193. 


COMPLICATIONS.  233 

possible,  particularly  in  the  most  internal  layers  of  the  organ,  to 
see  with  the  naked  eye,  that  tlie  vessels  are  gorged  with  blood. 
There  ordinarily  result  from  it  an  infiltration  and  .  a  softening, 
which  are  much  greater  in  the  layers  of  the  parenchyma  of  the 
uterus  nearest  to  the  mucous  membrane.  Hence,  these  alterations 
of  tissue  which  are  characteristic  of  acute  parenchymatous  metritis 
ordinarily  accompany  catarrh  of  the  mucous  membrane,  when  this 
has  obtained  a  high  degree  of  intensity."  "The  whole  substance 
of  the  uterus,"  says  Klob,'  "generally  appears  to  be  increased,  and 
its  tissue  more  vascular  and  succulent,  especially  in  the  layers 
nearest  the  mucous  membrane." 

Acute  endometritis  very  rarely  shows  itself  before  puberty. 

Complications. — Its  complications  are  acute  metritis,  urethritis, 
vaginitis,  vulvitis,  cystitis,  salpingitis,  pelvic  peritonitis,  and 
various  eruptive  disorders,  the  results  of  scratching  excited  by 
pruritus  vulvae. 

The  first  of  these  complicating  conditions  is  of  so  much  moment 
as  to  require  special  consideration. 

The  time  has,  I  think,  arrived  when,  with  our  present  light  upon 
the  subject,  acute  parenchymatous  metritis  should  be  given  a  subor- 
dinate place  in  pathology  instead  of  the  prominent  one  which  it 
formerly  occupied.  With  reference  to  its  frequency  as  a  primary 
affection,  many  conflicting  statements  will  be  found.  This  arises 
partly  from  the  fact  that  some  have  written  of  it  without  making 
any  distinction  between  the  forms  occurring  in  the  puerperal  and 
non-puerperal  states,  while  others  have  confined  their  remarks,  as 
is  here  done,  to  the  disease  in  the  latter  condition ;  ])artly  from 
endometritis,  active  congestion  from  suppressio  mensium,  and  peri- 
tonitis and  cellulitis  having  been  mistaken  for  metritis;  and  in 
great  part  from  the  difiiculty  of  gaining  post-mortem  evidence,  the 
disease  generally  being  recovered  from.  As  a  complication  of  in- 
flammation of  the  internal  mucous  or  external  serous  covering  of 
the  uterus,  parenchymatous  inflammation  is  universally  admitted. 
As  a  pathological  entity,  however,  I  question  whether  any  well 
authenticated  case  of  this  affection  is  on  record.  The  descriptions 
of  the  disease  which  are  given  in  recent  works,  such,  for  example, 
as  those  of  Courty,  Gallard,  and  Scanzoni,  each  of  whom  devotes 
considerable  space  to  it,  appear  to  me  to  have  come  down  to  us  as  a 
matter  of  literary  tradition  rather  than  of  clinical  research. 

'  Path.  Anat.  Female  Sex.  Organs,  American  ed.,  p.  231. 


234  ACUTE    ENDOMETRITIS. 

While  searcliing  for  a  case  of  pure  uncomplicated  metritis,  I 
have  seen  numbers  of  cases  which  were  regarded  hy  others  as  of 
this  character,  and  quite  a  number  which  I  viewed  as  such  until 
enlightened  by  post-mortem  or  other  evidence.  Rokitansky^  de- 
clares that,  "  in  acute  inflammation  of  this  organ,  generally  the 
lining  membrane  of  the  uterus  is  affected  primarily,  and  that  this 
is  scarcely  ever  the  case  with  the  uterine  tissue,  as  far  as  can  be 
demonstrated  by  the  pathological  anatomist,  with  the  exception 
of  the  reaction  following  traumatic  influences,  especially  of  the 
vaginal  portion." 

In  his  recent  work  Klob^  takes  still  stronger  ground  as  to  the 
existence  of  uncomplicated  metritis,  and  asserts  that  never  having 
met  with  an  instance  of  the  disease,  he  is  forced  to  describe  it  upon 
the  authority  of  others. 

Some  practitioners  are  prone  to  regard  every  case  of  inflamma- 
tory action  in  the  pelvis,  accompanied  by  great  tenderness  ovep 
the  uterus,  as  metritis.  Such  cases  are  much  more  frequently  due 
to  pelvic  cellulitis  or  peritonitis,  which  are  by  no  means  rare  affec- 
tions, or  to  active  congestion,  caused  by  suppression  of  the  menses 
or  excessive  coition.  After  parturition,  either  at  term  or  prema- 
ture, true  metritis  does  occur  not  unfrequently,  but  this  variety 
does  not  concern  our  present  investigation.  As  regards  that  form 
which  we  are  considering,  T  feel  convinced  that  if  the  experienced 
practitioner  will  put  aside  his  preconceived  views  and  interrogate 
the  results  of  his  oljservation,  he  will  find,  if  he  has  had  his  atten- 
tion aroused  to  the  frequency  of  the  diseases  which  simulate  it, 
that  he  has  met  with  this  affection  very  rarely. 

Course,  Diu^ation.,  and  Termination. — Acute  endometritis,  when 
occurring  in  the  non-puerperal  state,  may,  without  treatment  even, 
go  on  to  recovery,  generally  lasting  from  a  month  to  six  weeks, 
and  perhaps  passing  through  its  whole  course  without  its  existence 
having  been  diagnosticated.  It  sometimes  ends  in  the  chronic  form 
of  mucous  inflammation,  or  even  in  slight  hyperplasia,  the  super- 
ficial subjacent  connective  tissue  becoming  affected.  It  is  doubtful 
whether  any  severe  case  of  endometritis  runs,  its  course  without 
being  to  a  greater  or  less  extent  complicated  l)y  a  slight  degree  of 
parenchymatous  disorder.  As  already  stated  the  disease  may  end 
in  chronic  endometritis  or  in  recovery.  It  may,  likewise,  end  in 
death  ;  inflammatory  action  spreading  along  the  Fallopian  tubes 


'  Patholofiry  Anat. 

2  Path.  Aiiat.  Female  8ex.  Organs,  American  ed.,  p.  231. 


TREATMENT.  235 

and  causing  salpingitis,  which,  by  resulting  in  free  purulent  dis- 
charge into  the  peritoneum,  may  establish  inflammation  there. 

Prognosis. — In  spite  of  all  these  possibilities  the  prognosis  is 
always  favorable  if  the  patient  take  ordinary  care  of  herself  and 
yield  to  a  judicious  plan  of  treatment. 

Treatment. — The  diagnosis  having  been  clearly  made,  treatment 
should  be  at  once  established.  Complete  rest  of  mind  and  body 
should  be  regarded  as  essential  points.  In  severe  cases,  the  pa- 
tient should  be  kept  perfectly  quiet  upon  her  back  in  bed,  and 
not  allowed  to  leave  it  or  to  assume  the  sitting  posture  even  to 
satisfy  the  calls  of  nature.  Opium  should  be  freely  given  by 
mouth  or  rectum  for  the  production  of  perfect  nervous  quiescence 
and  for  the  relief  of  pain.  In  severe  cases  one  grain  of  powdered 
opium  or  its  equivalent  of  morphia  should  be  administered  every 
third  hour.  This  drug,  I  feel  sure,  not  only  acts  as  a  sedative  to  the 
nervous  system,  and  a  quieter  of  pain ;  it  absolutely  modifies  the 
inflammatory  process  by  its  influence  upon  the  nerves.  The  bowels, 
unless  constipation  exists,  should  not  be  acted  upon  b}^  cathartics, 
and  ordinarily  no  other  medicine  than  opium  should  be  adminis- 
tered. Over  the  hypogastrium  a  soft,  warm  poultice  of  powdered 
linseed  should  be  placed  and  covered  by  oiled  silk.  This  need  not 
be  renewed  oftener  than  once  in  twelve  hours,  for  the  oiled  silk 
will  preserve  its  warmth.  The  patient  should  not  be  annoyed  by 
leeches  or  cups.  Even  if  high  febrile  action  show  itself,  this  can 
be  readily  controlled  by  appropriate  administration  of  tincture  of 
veratrum  viride.  The  diet  should  be  very  simple,  and  should  con- 
sist of  fluid  food  chiefly,  as  milk,  beef-tea,  etc.  A  condition  of  in- 
testinal quietude  should  be  encouraged,  and  therefore  such  food  as 
involves  the  elimination  of  a  small  amount  of  excrementitious 
matter  should  be  allowed.  By  these  means  motion  in  the  abdomi- 
nal cavity  may  be  lessened  and  rest  be  assured  to  the  diseased 
part.  As  soon  as  free  secretion  of  muco-pus  begins  to  show  itself, 
the  vagina  should  be  gently  syringed  out  three  times  daily  with 
copious  warm  injections  of  infusions  of  bran,  linseed,  starch,  or 
})oppies.  For  the  proper  accomplishment  of  this  the  patient 
should  turn  so  as  to  lie  across  the  bed,  in  the  French  obstetric 
position,  on  the  back,  with  the  buttocks  over  the  edge  of  the 
bed,  which  has  been  protected  by  India-rubber  cloth,  each  foot 
being  supported  by  a  chair.  A  nurse,  then  placing  between  the 
thighs  a  tub  containing  three  or  four  gallons  of  the  selected  in- 
fusion, should  pass  the  nozzle  of  a  Fountain  or  a  Davidson's 
syringe  up  to  the  cervix,  and  for  fifteen  minutes  project  against 


236  CHRONIC    CERVICAL    ENDOMETRITIS. 

it  a  steady  stream.  All  examination  by  speculum,  probe,  and, 
after  a  diagnosis  has  been  made,  even  by  the  finger,  should  be 
avoided  unless  some  special  indication  demand  it.  Astringent 
injections  and  all  vaginal  applications  should  be  avoided.  The 
afi'ection  which  we  are  treating  is  located  in  the  uterus,  not  in  the 
vagina,  and  such  applications  merely  annoy  the  patient  and  aggra- 
vate the  disease.  The  warm  injections  which  have  been  advised 
act  as  poultices  or  fomentations  to  the  whole  internal  surface  of 
the  pelvis,  at  the  same  time  that  they  insure  cleanliness  to  the 
•vagina  and  remove  from  it  a  fluid,  which  if  left  there  might  excite 
vaginitis.  Under  this  plan  of  treatment  the  patient  should  be 
kept  until  recovery,  or  until  we  are  admonished  by  time  that  the 
disease  has  passed  into  its  chronic  form  and  requires  difl[:erent  reme- 
dies. 

To  one  accustomed  to  the  advice  to  apply  leeches  to  the  cervix 
or  perineum,  pass  the  speculum,  and  apply  solid  nitrate  of  silver 
to  the  cervical  canal,  inject  the  vagina  with  solutions  of  persulphate 
of  iron,  keep  the  bowels  constantly  active  by  saline  cathartics,  etc., 
this  plan  may  appear  too  inefficient  to  be  relied  upon.  Of  any 
one  entertaining  this  doubt  I  Avould  ask  a  trial  and  comparison  of 
the  two  methods  before  he  arrives  at  a  decision  which  will  guide 
his  future  practice.  If  his  experience  agree  with  mine  I  do  not 
doubt  the  resulting  verdict. 


CHAPTER    XIV. 

CHRONIC  CERVICAL  ENDOMETRITIS. 

When  inflammation  of  acute  character  aflfects  the  uterus  it  has 
a  marked  tendency  to  invade  the  entire  organ,  and  to  involve  both 
cervix  and  body,  but  with  chronic  inflammation  this  is  not  the 
case.  Being  of  a  lower  grade  of  intensity,  it  more  strictly  confines 
itself  to  the  mucous  membrane  and  limits  itself  to  the  body  or 
cervix.  Such  limitation  is,  however,  neither  universal  nor  absolute, 
sometimes  subjacent  parts  being  more  or  less  implicated,  and  at 
others  the  mucous  membrane  of  the  entire  organ  being  simulta- 
neously and  equally  involved. 

Definition.— V>j  the  term  chronic  cervical  endometritis  is  meant 
chronic  inflammation  of  the  mucous  membrane,  extending  from  the 


FREQUENCY  —  SYNONYMS. 


237 


OS  internum  to  the  os  externum,  as  represented  by  the  dots  in 

Fig.  66. 


Fig.  ae. 


The  dots  represent  the  site  of  chronic  cervical  endometritis. 

Frequency. — Of  all  diseases  of  the  genital  system  of  the  female 
this  'is  without  doubt  the  most  frequent,  and  although  not  in  itself 
a  malady  of  dangerous  character  may  prove  the  starting  point  for 
some  of  the  most  serious  and  rebellious  of  uterine  disorders. 
Exposed  as  the  cervix  uteri  is  to  injiirj^  during  coition,  laceration 
from  parturition,  and  irritation  from  walking,  riding,  and  lifting, 
it  is  not  surprising  that  its  complicated  investment  should  fre- 
quently become  the  seat  of  disease. 

Synonyms. — It  has  been  described  under  the  names  of  cervical 
catarrh,  cervical  leucorrhcea,  and  endo-cervicitis. 

Anatomy  of  the  Cervical  Mucous  Ilemhj^ane. — The  cavity  of  the 
cervix  uteri  is  a  fusiform  canal,  measuring  about  one  inch  and  a 
quarter,  beginning  at  the  os  internum  above  and  ending  at  the  os 
externum  below.  On  the  anterior  and  posterior  walls  of  the  cervix 
are  ridges,  from  which  folds  are  given  off  which  are  arranged  with 
regularity,  and  run  obliquely  upwards  and  outwards,  to  end  in 
other  indistinct  lines  on  the  sides  of  the  canal.  This  arrangement 
of  mucous  membrane  has  received  the  name  of  arbor  vitfB. 

Between  these  folds  numerous  mucous  glands  are  seen,  which  are 


238 


CHRONIC    CERVICAL    ENDOMETRITIS. 


called  by  some  the  glands  of  Nabotli,'  Dr.  Tyler  Smitli^  estimates 
that  a  well  developed  virgin  cervix  probably  contains  at  least  ten 
thousand  of  these  follicles.  The  mucous  membrane  forming  these 
folds  or  rugfe  is  covered  over  by  cylindrical  and  ciliated  epithelium 
and  studded  by  villi,  which  are  found  in  considerable  numbers 
upon  the  larger  rugfe  and  other  parts  of  the  mucous  membrane. 
(Fig.  67.) 

The  natural  secretion  of  the  cervical  canal  has  been  shown  by 
M.  Donne  to  be  alkaline,  unlike  that  of  the  vagina,  which  is  acid. 


Fi-.  67. 


Villi  of  canal  of  the  cervix  uteri,  covered  by  cylindrical  epithelium  and  containing 
looped  bloodvessels.     One  hundred  diameters.     (T.  Smith.) 

Pathology. — Cervical  endometritis  consists  in  inflammation  of  all 
this  structure  and  consequent  alteration  of  its  condition.  The 
raucous  glands  are  especially  involved  in  the  morbid  action,  the 
disease  chiefly  consisting  in  glandular  inflammation.  The  glairy 
mucus  which  is  secreted  in  large  amount  as  one  of  its  symptoms 
is  the  characteristic  discharge  of  these  structures.  Looked  at  with 
a  strong  glass  in  post-mortem  examinations  of  this  disease,  they 
are  seen  enlarged  and  elevated,  and,  according  to  Aran,^  their 

'  A  great  deal  of  obscurity  attaches  to  the  nature  and  functions  of  these  glands. 
Some  regard  the  Nabothian  glands  as  identical  with  the  muciparous  follicles,  others 
look  upon  them  as  occluded  glands  distended  by  their  retained  secretion. 

^  On  Leucorrhcea,  Am.  ed.,  p.  38. 

^  Mai.  de  I'Utferus,  p.  423. 


PREDISPOSING    CAUSES.  239 

iiioutlis  may  be  seen  very  much  dilated.  In  some  cases  it  becomes 
complicated  by  granular  degeneration.  The  villi  or  papillae,  espe- 
cially those  on  the  vaginal  face  of  the  cervix,  become  diseased. 
At  lirst  there  is  a  loss  of  the  normal  supply  of  epithelium,  which 
produces  a  slight  and  very  superficial  abrasion.  This  becomes  in 
time  more  distinct  and  marked,  from  destruction  of  the  villi  them- 
selves over  spaces  of  greater  or  less  extent.  If  this  process  of  de- 
struction should  go  on  and  aftect  the  deeper  tissue,  a  true  ulcer 
would  be  formed,  and  no  one  would  ever  have  denied  the  name  of 
ulceration  to  the  existing  condition,  but  it  does  not  thus  progress. 
In  time  an  hypertrophy  occurs  in  the  villi,  which  increase  in  size, 
project  like  so  many  hairs  from  the  surface,  and  give  to  the  os  and 
cervix  an  appearance  which  has  caused  the  term  granular  degene- 
ration to  be  applied  to  it.  This  state  affects  the  vaginal  portion  of 
the  cervix  chiefly,  but  may  extend  up  the  canal. 

Another  pathological  state,  which  is  occasionally  met  with  as  a 
complication  of  cervical  endometritis,  is  an  eversion  of  the  os  and 
lower  portion  of  the  canal  to  such  an  extent  as  to  keep  up  inflam- 
mation there  by  the  friction  of  the  membrane,  thus  exposed,  against 
the  floor  of  the  pelvis.  Some  very  obstinate  cases  are  due  to  this 
condition. 

The  diseased  mucous  membrane  pours  forth  with  great  activity 
large  amounts  of  thick,  tenacious  mucus,  which  is  loaded  with 
epithelium  and  sometimes  tinged  with  blood. 

Predisposing  Causes. — It  is  a  matter  of  some  moment  that  the 
etiology  of  this  aft'ection  should  be  studied  under  two  heads — pre- 
disposing and  exciting.     The  former  includes: 

Natural  feebleness  of  constitution ; 

The  existence  of  a  cachexia,  as  tuberculosis  or  scrofula; 

Impoverishment  of  the  blood  from  chlorosis  or  other  cause ; 

Prolonged  mental  depression; 

Insuflicient  nutriment ; 

Excessive  lactation ; 

Frequent  parturition; 

Subinvolution; 

Styles  of  dress  which  depress  the  uterus; 

"Want  of  exercise  and  fresh  air. 

« 
These  influences  either  act  injuriously  uyton  the  nervous  system, 
and  thus  interfere  w'lfh  the  circulation  and  nutrition  of  the  lining 
membrane  of  the  cervix;  or  by  directly  disordering  the  vessels  and 


240  CHRONIC    CERVICAL    ENDOMETRITIS. 

nerves  of  the  uterus  render  it  ready  for  the  establishment  of  disease 
bv  some  cause  which  would  have  exerted  no  baneful  effect  upon  a 
woman  in  perfect  health. 

It  may  naturally  be  asked  why  these  influences  should  cs[)e- 
cially  produce  this  disease.  My  answer  is,  that  they  do  not  do  so. 
Sometimes  they  cause  chronic  pneumonia;  at  other  times  granular 
eyelids;  at  others  follicular  faucitis;  and  again  at  others  chronic 
cervictal  endometritis. 

Exciting  Causes.— ChM  among  these  may  be  enumerated: 

Displacements  of  the  uterus; 

Excessive  or  intemperate  coition; 

The  use  of  intra-uterine  pessaries; 

Puerperal  endometritis ; 

Acute  non-puerperal  endometritis ; 

Exposure  or  tatigue  affecting  a  subinvoluted  uterus; 

Efforts  at  production  of  abortion  and  prevention  of  conception ; 

Vaginitis,  specific  or  simple  ; 

Obstructive  dysmenorrhoea ; 

Cervical  polypi ; 

Laceration  of  the  cervix. 

Many  other  causes  might  be  enumerated ;  but  these  wnll  suffice 
to  show  the  nature  of  those  influences  which  act  as  excitants  of  the 
disease.  Many  of  those  mentioned  would  fail  to  produce  it  in  a 
uterus  which  had  not  been  prepared  for  their  action  by  depreciating 
constitutional  conditions.  "When  treatment  is  established  for  the 
cure  of  the  disease,  if  it  be  inaugurated  and  pursued  without  re- 
gard to  the  predisposing  causes,  it  will  often  prove  inefficient  or 
futile  in  cases  which  would  yield  to  a  plan  that  showed  a  recogni- 
tion of  their  importance.  Appreciating  highly,  as  I  do,  the  value 
of  local  treatment  in  uterine  affections,  were  I  in  the  management 
of  this  disease  limited  entirely  to  one  kind — local  or  general — I  do 
not  hesitate  to  say  that  I  would  infinitely  prefer  the  latter.  A 
removal  from  a  city  to  the  country,  the  use  of  mineral  and  vegeta- 
ble tonics,  plenty  of  good,  nutritious  food,  the  observance  of  regular 
hours,  the  systematic  practice  of  exercise  in  the  fresh  air,  and  the 
pleasures  of  cheerful  society,  will,  I  feel  confident,  do  far  more  for 
the  patient  than  a  weekly  visit  to  the  office  of  a  physician  and  the 
reception  of  the  most  appropriate  local  treatment  which  science  can 
aflford.  But  better  than  either  plan  is  the  judicious  combination 
of  the  two.     They  should  go  hand  in  hand.     My  wish  is  to  keep 


SYMPTOMS.  241 

prominent  the  fact,  that  of  the  two  the  general  treatment  is  the 
more  important  in  the  disease  which  now  concerns  us,  as  it  is  in 
many  others  wliich  we  sliall  come  to  consider. 

S/^iiip(oiii.6: — -Cervical  endometritis  may  exist  for  a  length  of  time 
without  presenting  any  symptoms  of  sufficient  gravity  to  warn  the 
patient  of  its  ])resence.  Even  a  leucorrha^a,  which  is  somewhat 
abundant,  often  fails  to  attract  her  attention.  The  answer  to  a 
([uestion  as  to  its  existence  will  often  be  a  negative  one  in  cases  in 
wiiich  the  practitioner  will,  by  the  speculum,  discover  a  considera- 
ble amount  in  the  vagina.  In  the  great  majority  of  cases  the  dis- 
ease will  soon  announce  its  existence  by  some  or  all  of  the  following 
signs.  The  first  symptom  which  will  attract  attention  will  proba- 
bly be  dragging  sensations  about  the  pelvis.  These  will  soon  be 
followed  by  pain  in  the  back  and  loins,  which  will  be  very  much 
increased  by  exercise  or  nmscular  efforts.  Then  a  more  or  less  pro- 
fuse leucorrlioea  will  be  noticed,  the  discharge  as  it  issues  from  the 
vulva  resembling  boiled  starcli  or  thick  gum-water,  and  often  irri- 
tating the  vulva  and  vagina  to  such  an  extent  as  to  })roduce  inflam- 
mation in  them.  Menstrual  disorders  may  now  show  themselves. 
The  discharge  may  l)e  either  too  scanty  or  too  profuse,  too  frequent 
or  too  infrequent,  and  to  a  certain  extent  painful ;  sometimes, 
though  not  often,  decided  dysmenorrhoea  will  exist. 

Usually  before  the  disease  has  existed  for  a  long  period,  the 
constitution  of  the  patient  will  show  signs  of  becoming  implicated. 
She  will  become  nervous,  irascible,  moody,  and  often  hysterical. 
Her  appetite  will  diminish  and  digestion  grow  feeble,  so  that 
impoverished  blood  will  soon  be  observed  as  a  result  of  impaired 
nutrition.  With  some  or  all  of  these  signs  of  the  existing  disorder 
the  patient  may  continue  for  a  length  of  time  without  suftering 
from  others  of  more  annoying  or  graver  character.  Complica- 
tions may,  however,  rapidly  develop  themselves;  cystitis,  cervical 
hyperplasia,  and  vaginitis  coming  on  and  proving  exceedingly 
troublesome.  At  times  pain  during  sexual  intercourse  constitutes 
a  prominent  sign  of  cervical  disease,  1)ut  it  belongs  rather  to  cer- 
vical hyperplasia  than  to  endometritis,  the  former  having  added 
itself  as  a  complication  to  the  latter,  and  thus  produced  the  symp- 
tom. Sometimes  nausea,  and  even  vomiting,  present  themselves 
as  symptoms,  and  these,  together  with  the  digestive  disorder  before 
mentioned,  produce  a  deterioration  in  the  nutrition  of  the  patient. 

Although  these  symptoms  are  enough  to  make  us  confident  of 
the  existence  of  uterine  disorder,  they  by  no  means  furnish,  reliable 
16 


242  CHRONIC    CERVICAL    ENDOMETRITIS. 

2:rounds  for  a  positive  diagnosis.  This  can  be  arrived  at  only  by 
physical  exploration. 

Physical  Signs.— The  patient  being  placed  upon  her  back,  and  the 
linger  of  the  examiner  introduced  into  the  vagina,  the  os  uteri  will 
probably  be  found  in  its  usual  position  in  the  pelvis,  for  the  weight 
of  the  uterus  is  not  increased,  the  connective  tissue  not  being 
involved.  The  os  may  be  somewhat  enlarged  and  its  lips  slightly 
puffed,  or  it  may  be  roughened  on  account  of  granular  degene- 
ration. Sometimes,  however,  severe  cervical  endometritis  may 
exist  without  any  enlargement  of  the  os,  or  any  trace  of  abrasion 
or  granular  degeneration.  If  the  finger  be  placed  under  the 
cervix  and  that  part  raised  by  it,  pain  will  be  complained  of, 
though  not  to  any  great  extent.  This  will  be  most  marked 
near  the  os  internum.  ISTo  other  affirmative  sign  can  be  elicited 
by  this  means,  and  the  speculum  should  then  be  used.  By  this 
the  OS  will  be  seen  to  be  in  the  condition  just  described,  and 
from  it  will  be  found  to  exude  a  long  string  of  tough,  tenacious 
mucus  which  will  closely  resemble  the  white  of  Qgg.  If  entangled 
by  a  small  mass  of  cotton  attached  to  the  end  of  a  wlial(?bone  rod, 
it  will  be  found  to  be  so  viscid  and  resisting  that  it  cannot  be 
drawn  from  the  canal.  It  will  resist  even  a  stream  of  water  thrown 
with  some  force  upon  it,  and  very  often  is  removed  only  after 
several  efforts  by  this  or  other  means.  The  cervix  will  usually  be 
found  to  be  somewhat  enlarged.  Its  tissue  may  present  a  swollen, 
puffed  appearance,  or  be  intensely  red  as  if  in  a  state  of  granular 
degeneration,  which  will  upon  close  inspection  be  found  to  be  due 
to  removal  of  its  investing  epithelium  and  the  occurrence  of  hyper- 
trophy of  the  villi.  Should  this  condition  exist,  it  will  afford 
relief  to  the  mind  of  the  inexperienced  gynecologist,  for  the  diag- 
nosis of  the  case  will  be  clear.  But  another  state  of  things  may  be 
discovered  which  will  leave  him  in  doubt.  Upon  removing  the 
plug  of  obstructing  mucus,  he  may  discover  no  evidence  of  disease. 
The  OS  is  no  larger  than  it  should  be,  its  tissue  is  not  reddened,  no 
degeneration  exists,  in  fact  nothing  is  found  explaining  the  back- 
ache, nervousness,  impaired  nutrition,  and  profuse  leucorrhoea 
which  led  him  to  advise  and  urge  the  examination.  The  case  is 
simply  one  of  cervical  endometritis  which  affects  the  glands  of  the 
canal  without  having  produced  granular  degeneration. 

It  is  often  a  matter  of  great  difficulty  to  decide  whether  endo- 
metritis is  confined  to  the  neck  or  extends  through  this  part  into 
the  body.     In  many  cases  a  certain  conclusion  is  impossible.     The 


COUESE,    DURATION,   AND    TERMINATION.  243 

evidences  by  which  it  may  be  usually  arrived  at  are  these :  in  the 
former  case  the  neck  alone  is  found  enlarged  and  tender  to  touch, 
conjoined  manipulation,  and  the  probe;  in  the  latter,  the  body  also 
shows  these  signs  of  the  implication  of  its  tissues  in  the  morbid 
action.  The  discharge  resulting  in  the  former  is  more  thick,  tena- 
cious, and  difficult  of  removal  than  in  the  latter  variety.  Lastly, 
the  constitutional  symptoms  attending  the  latter  are  ordinarily 
graver  than  those  created  by  the  former. 

Course,  Duration,  and  Termination. — Cervical  endometritis  is  not 
a  self-limiting  disease,  and  consequently  its  duration  will  depend 
upon  circumstances  which  control  its  progress.  It  may  unques- 
tionably disappear  without  medical  aid.  Any  alterative  influence 
which  exerts  a  complete  change  in  the  economy,  as,  for  instance, 
parturition,  entire  alteration  of  the  habits  of  life,  or  some  change 
equally  decided,  sometimes  results  in  a  cure.  But  it  is  certainly 
safe  to  say  that,  unchecked,  it  frequently  passes,  in  multiparous 
women,  into  cervical  hyperplasia,  which  would  probably  draw  in 
its  train  displacement,  and  all  the  long  list  of  ailments  which 
make  the  lives  of  women  suffering  from  uterine  disease  so  burden- 
some. 

Prognosis. — The  prognosis  of  this  affection  will  depend  upon  the 
degree  of  glandular  disease  accompanying  it.  If  the  mucus  which 
marks  inflammation  of  the  glands  be  slight  in  amount,  aftd  not 
very  tenacious  in  character,  whatever  be  the  extent  of  coincident 
granular  degeneration,  the  prognosis  is  favorable.  When,  on  the 
other  hand,  there  is  little  granular  disease,  and  a  large  amount  of 
thick,  resisting  mucus  hangs  from  the  cervical  canal,  the  proo^nosis, 
according  to  my  experience,  is  very  doubtful,  and  sometimes  hope- 
less, unless  very  radical  measures  be  adopted.  If  each  will  look 
back  into  his  experience,  he  will  see  that  in  all  severe  cases  he  has 
either  been  forced  to  resort  to  measures  which  absolutelj^  destroy 
the  diseased  glands  for  their  cure,  or  that  the  patients  in  time, 
wearied  of  his  insuccess,  have  gone  for  treatment  elsewhere.  Let 
it  be  remembered  that  I  allude  now  only  to  very  severe  cases  where 
the  glands  are  profoundly  involved.  In  regard  to  such,  I  feel  sure 
that  the  experience  of  others  must  agree  with  mine. 

Even  in  minor  cases  great  caution  should  be  observed  as  to  fixino* 
the  time  at  which  recovery  will  take  place.  ,  Even  in  the  mildest 
case  which  has  lasted  for  some  time,  from  four  to  six  months  will 
probably  elapse  before  perfect  cure  can  be  accomplished,  and  even 
after  this  a  relapse  will  be  very  likely  to  occur  unless  preventive 
measures  be  adopted  and  strictly  adhered  to. 


244  CHRONIC    CEEVICAL    ENDOMETRITIS. 

Treatment— TliQ  disease  consisting  in  cervical  endometritis,  the 
efforts  of  the  practitioner  should  be  directed  to  producing  an  altera- 
tive influence  upon  a  mucous  membrane  which  is  in  a  condition  of 
chronic  inflammation,  and  the  avoidance  of  all  influences  which 
may  cause  it  to  spread  to  adjacent  tissues.  These  ends  will  be  best 
accomplished  by  the  following  means : 

General  regimen ; 

Emollient  applications ; 

Alterative  applications ; 

Ablation  or  destruction  of  the  diseased  glands. 

General  Regimen. — "  The  first  care  of  the  practitioner,"  says  Sir 
Charles  Clarke,  "  should  be  to  remove,  if  possible,  the  causes  of 

the  disease Women  who  live  in  a  moist  atmosphere, 

who  keep  bad  hours,  who  spend  much  of  their  time  in  bed,  or 
who  inhabit  hot  rooms  (being  generally  weak  women,  and  having 
a  relaxed  vagina),  will  be  apt  to  be  affected  by  the  comiJaint." 
All  such  unfavorable  circumstances  should  be  modified.  If  any 
depressing  influence,  such  as  lactation,  any  habitual  discliarge,  or 
any  cause  for  mental  anxiety,  be  discovered,  it  should  be  carefully 
removed,  and  the  patient,  unless  absolutely  plethoric,  be  put  upon 
the  use  of  vegetable  tonics,  the  mineral  acids,  and  preparations  of 
iron.  The  functions  of  the  alimentary  canal  should  be  constantly 
supervised.  The  diet  should  be  mild  and  unstimulating,  but 
most  nutritious.  ISTo  system  of  starvation  should  be  entered  upon, 
for  the  tendency  of  the  disease  is  to  the  production  of  spanjemia, 
and  this  we  should  combat.  All  spices  and  stimulating  condi- 
ments should  be  avoided.  Every  day,  unless  some  special  contra- 
indication exist,  the  patient  should  take  fresh  air  and  exercise,  by 
carriage  or  on  foot  for  a  time,  which  should  be  limited  by  the 
circumstances  of  the  particular  case.  If  she  should  be  unable  to 
do  this  from  any  cause,  she  should  be  thoroughly  protected,  and 
pure  air,  even  in  winter,  be  allowed  to  circulate  freely  in  her 
chamber,  all  the  doors  and  windows  of  which  should  be  opened 
for  two  or  three  hours  daily.  This  plan,  which  is  suggested  by 
Prof.  Byford,  of  Chicago,  I  have  found  a  most  excellent  one.  The 
bowels  should  be  kept  regular  by  saline  cathartics,  and  the  skin  in 
proper  state  by  occasional  baths.  Care  must  be  observed  not  to 
depreciate  the  strength  by  catharsis,  and,  to  prevent  this,  a  ferru- 
ginous tonic  may  be  advantageously  combined  with  the  cathartic, 
as  in  tlie  following  mixtures : 


TREATMENT.  245 

R. — Magnesiae  solphatis.  ^ij. 
Ferri  sulphatis,  gr.  xvj. 
Acidi  sulphurici  dil.  3j. 
Aquae,  Oj. — M. 
Ooe  ounce  (two  tablespooufuls)  in  a  tumbler  of  iced  water  every  morning  upon 
rising. 

R. — Sodae  et  potass,  tart.  5ij. 

Vini  ferri  amari  (U.  S.  D.),  3ij. 
Acidi  tartarici,  ^iij 
Aquae,  ^xiv. — M. 
One  ounce  in  a  tumbler  of  iced  water  every  morning  upon  rising. 

Sliould  one  draught  not  be  sufficient,  two  or  even  tliree  may 
be  taken  daily,  for  the  result  will  prove  tonic  and  reparative  as 
well  as  cathartic. 

If  much  disturbance  of  the  nervous  system  should  exist,  the 
bromide  of  potassium  in  doses  of  five  to  ten  grains,  three  times  a 
day,  will  be  found  very  useful. 

The  appetite  and  digestion  are  so  often  impaired  that  special 
attention  will  generally  have  to  be  directed  to  alleviation  of  that 
collection  of  symptoms  which  are  grouj^ed  under  the  head  of 
dyspepsia.  The  stomach  sympathiziiig  with  the  uterus  does  not 
perform  its  functions  with  vigor;  the  gastric  juices  appear  to  be 
wanting  or  inefficient,  and  fermentation  of  the  food  often  takes 
the  place  of  digestion.  Under  these  circumstances  I  can  recom- 
mend from  lengthy  experience  with  it  the  following  digestive 
tonic : 

R. — One  rennet,  washed  and  chopped. 
Sherry  wine,  Oj. 
Macerate  for  twelve  days,  then  decant,  filter,  and  add — 
Dilute  nitro-muriatic  acid,  3ij. 
Tinct.  of  nus  vomica,  ^ij. 
Subnitrate  of  bismuth,  .^ij. 
One  tablespoonful  in  a  quarter  of  a  tumbler  of  water  before  each  meal. 

This  prescription  combines  the  tonic  properties  of  nux  vomica 
and  the  peculiar  alterative  influences  of  bismuth,  with  a  fluid 
which  resembles  the  gastric  juice.  In  many  cases  of  habitual 
indigestion  I  have  obtained  from  it  the  best  results. 

Emollient  Applications. — The  cervix  should  be  irri2:ated  every 
night  and  morning,  by  warm  water  thrown  against  it  by  one  of 
the  plans  recommended  elsewhere.  To  the  water  may  be  added 
chloride  of  sodium,  glycerine,  boiled  starch,  infusion  of  linseed, 
slippery  elm,  or  tincture  of  opium.     The  irrio-ation  should  be  so 


246  CHRONIC    CERVICAL    ENDOMETRITIS. 

planned  as  to  last  for  ten  or  fifteen  minutes  without  fatiguing  the 
patient  or  proving  a  source  of  annoyance  to  her.  The  methods 
for  doino-  this  are  so  fully  described  elsewhere  that  they  need  not 
be  repeated  here. 

In  many  cases  of  this  affection  of  not  very  aggravated  character, 
and  which  have  not  advanced  to  the  production  of  granular  degen- 
eration or  hyperplasia,  if  this  plan  of  general  tonic  treatment  and 
soothing  injections  be  faithfully  carried  out,  all  complaints  will 
cease  on  the  part  of  the  patient,  and  a  cure  be  gradually  effected. 
Should  this  result  not  be  attained,  or  should  the  disease  be  dis- 
covered at  the  first  examination  to  have  profoundly  involved  the 
cervical  glands,  resort  must  be  had  to  apj)lications  to  the  diseased 
surface  through  the  speculum. 

In  cases  in  which  the  lining  membrane  of  the  cervix  is  in  a  con- 
dition of  granular  degeneration,  and  the  mucous  glands  are  very 
little  aflected,  cure  can  be  almost  as  readily  accomplished  as  where 
the  same  granular  disease  exists  on  the  vaginal  face  of  this  part. 
But  such  cases  will  be  treated  of  under  the  caption  of  "  Granular 
Degeneration  of  the  Cervix ;"  they  do  not  properly  come  under 
consideration  at  the  same  time  with  the  move  obstinate  disease  of 
the  glands.  To  make  this  statement  more  clear;  cervical  endo- 
metritis consists  of  glandular  inflammation,  which  is  sometimes 
complicated  by  granular  degeneration.  In  some  cases  the  glands 
are  very  slightly  diseased,  while  the  villi  of  the  canal  are  decidedly 
so ;  these  come  under  consideration  rather  as  "  Granular  Deo-ene- 
ration,"  which  will  be  treated  of  elsewhere,  than  of  true  endome- 
tritis. 

Alterative  Applicaiions.^-lt  will  be  found  that  cervical  endome- 
tritis, existing  in  a  canal  the  os  externum  of  which  is  contracted, 
will  always  prove  much  more  difficult  of  cure  than  in  one  where  this 
part  is  dilated.  The  degree  of  dilatation  will  generally  be  found  to 
exert  a  marked  influence  over  the  tractability  of  the  case.  When 
then  it  is  discovered  that  the  disorder  does  not  disappear  under 
the  influence  of  time,  and  the  simple  measures  already  mentioned, 
as  one  of  ordinary  catarrh,  it  is  always  advisable  to  dilate  this 
part  before  proceeding  with  more  decided  measures.  If  this  be 
neglected,  and  the  practitioner  satisfy  himself  with  passing  through 
the  constricted  orifice,  nitrate  of  silver,  iodine,  pencils  of  zinc, 
alum,  iron,  etc.,  once  or  twice  a  week,  no  good  whatever  will  result. 
After  months,  or  even  years,  of  treatment,  he  will  discover  that  the 
mild  means  which  he  has  adopted  have  left   the   disease  uncon- 


ALTERATIVE    APPLICATIONS.  247 

trolled;  or  that  the  severe  ones  have  increased  contraction  of  the 
OS,  which  renders  menstruation  diiiicult  and  painful. 

The  best  and  simplest  method  for  overcoming  the  difficulty,  is  to 
snip  the  external  fibres  of  the  os  by  scissors  for  a  quarter  of  an  inch, 
touch  the  raw  surfaces  thus  made  with  nitrate  of  silver  or  solution 
of  persulphate  of  iron  to  prevent  union,  and  keep  plugs  of  greased 
lint  or  cotton  in  the  canal  for  a  week.  Should  there  be  any  objec- 
tion to  this  procedure,  which  is  painless,  free  from  danger,  and 
eflectual,  the  same  thing  may  be  imperfectly  accomplished  by 
repeated  dilatation  by  metallic  sounds,  or  by  the  use  of  a  tent  of 
sea-tangle  or  sponge.  The  use  of  a  tent  which  dilates  the  os  ex- 
ternum, not  passing  within  the  os  internum,  is  to  a  certain  extent 
free  from  the  dangers  attaching  to  those  which  invade  the  body. 
The  OS  externum  having  been  dilated  b}^  one  of  these  methods,  the 
first  if  there  be  no  special  objection  to  it,  so  that  free  escape  of 
the  secretion  of  the  muciparous  glands  may  occur,  the  canal  must 
be  thoroughly  cleansed.  Unless  this  be  systematically  done  it  will 
be  imperfectly  accomplished,  and  the  thick,  tenacious  material  M'ill 
completely  shield  the  diseased  glands  and  neutralize  any  chemical 
agent  before  it  can  reach  them.  The  most  efficient  means  for 
removing  this  plug  is  the  syringe  represented  in  Fig.  68.  It  is  a 
sj^ringe  of  hard  rubber,  two  inches  in  circumference,  holding  an 
ounce,  and  so  arranged  as  to  be  worked  with  one  hand,  the  index 
and  middle  fingers  surrounding  the  neck,  and  the  thumb  retracting 
the  piston.  Upon  the  extremity  of  its  long  pipe  is  slipped  a  bit 
of  gutta-percha  tubing,  the  free  portion  of  which  ])rojects  half  an 
inch.  This  free  portion  readily  enters  the  cervix,  and  goes  up  to 
the  OS  internum.  "When  introduced,  the  piston  is  ])Owerfully  re- 
tracted, the  mucous  plug  is  sucked  in,  and  the  cervix  is  left  entirely 
clean. 

Fiff.  68. 


DAHftOVH  tc  CO. 


Syringe  for  removing  cervical  mucus. 


Where  the  material  w^hich  covers  the  os  is  purulent  or  starchy, 
and  not  tenacious,  a  stream  of  water  may  be  projected  from  this 
syringe  against  the  cervix,  and  the  whole  be  removed  by  suction ; 


248  CHRONIC    CERVICAL    EK  DOMETRITIS. 

or  this  may  be  done  by  a  small  pledget  of  cotton  wrapped  around  a 
staff  of  whalebone,  hickory,  or  bamboo,  eight  inches  long,  as  thick 
as  a  pipe-stem,  and  tapering  toward  its  extremity.  Should  the 
first  pledget  become  saturated,  it  can  readily  be  slipped  from  the 
staff  and  another  wrapped  in  its  place,  or  several  staves  may  be 
prepared  and  kept  ready  for  use. 

Fig.  69. 


Rod  eight  or  nine  inches  long,  wrapped  with  cotton. 

When  the  characteristic  plug  of  tenacious  mucus  is  present,  there 
are  but  two  methods  which  entirely  remove  it:  one  is  the  exhausting 
syrino-e ;  the  other  the  use  of  a  dry  sponge  as  large  as  a  raspberry 
iixedin  a  long-handled  sponge  holder,  or  held  in  long  dressing 
forceps,  and  passed  into  the  cervical  canal  and  rotated  so  as  to 
entangle  the  thick  mucus.  The  sponge  should  be  thrown  away 
afterwards,  for  the  repetition  of  its  use  might  convey  disease  from 
one  patient  to  another.  A  supply  of  such  small  i)ieces  of  s])onge 
should  be  kept  at  hand,  in  order  that  a  new  one  may  be  used  for 
each  patient.  After  having  been  cleansed  by  one  of  these  methods, 
the  cervical  mucous  membrane  is  exposed,  and  applications  can 
be  made  to  it  with  some  prospect  of  their  coming  in  contact  with 
the  diseased  glands  embedded  in  the  jungle  of  convolutions  which 
constitute  the  arbor  vitse.  A  neglect  of  the  systematic  removal  of 
this  material,  I  believe  often  prevents  cure,  and  hence  I  am  so 
minute  in  reference  to  what  may  appear  an  insignificant  point. 

It  is  a  fact,  universally  admitted  in  every  department  of  thera- 
peutics, that  certain  substances  of  greater  or  less  strength  as  escha- 
rotics  have  the  property,  when  applied  to  inflamed  mucous  surfaces, 
of  so  modifying  the  morbid  action  existing  in  them  as  to  diminish 
its  intensity  and  in  time  to  cheek  its  progress.  It  is  upon  this 
principle  that  chronic  inflammations  of  the  fauces,  urethra,  bladder, 
and  many  other  mucous  surfaces  are  treated,  and  it  is  equally 
applicable  to  the  part  which  we  are  considering.  Alterative  and 
escharotic  substances  may  be  applied  to  the  lining  membrane  of  the 
cervix  uteri  in  the  following  ways:  by  painting  solutions  over  the 
canal  by  a  brush  or  dossil  of  lint,  by  touching  the  whole  diseased 
area  with  drugs  in  solid  form,  or  by  leaving  them  for  varying 
lengths  of  time  in  contact  with  the  walls  of  the  canal  in  a  solid 


« 


ALTEKATIVE    APPLICATIONS.  249 

/brill,  or  upon  cotton  which  has  been  saturated  with  solutions  of 
them. 

Should  the  case  be  one  of  short  standing  and  of  no  great  degree 
of  severity,  the  cervical  canal  should  be  thoroughly  painted  over 
with  the  compound  tincture  of  iodine,  a  strong  solution  of  nitrate 
of  silver,  glycerine  saturated  with  tannin,  or  a  saturated  solution  of 
sulphate  of  zinc,  or  copper.  This  may  be  done  by  using  a  brush 
of  pig's  bristles,  which  is  far  superior  to  one  of  camel's  hair;  or, 
by  wrapping  cotton  around  a  delicate  probe  of  silver  or  whalebone 
and  saturating  this  with  the  solution.  Emmet's  silver  or  Budd's 
vulcanite  probe  answers  an  excellent  purpose. 

Fisr.  70. 


Budd's  elastic  probe. 

Should  the  practitioner  prefer  to  use  a  solid  caustic,  the  nitrate 
of  silver  may,  with  great  advantage,  be  employed,  though  the 
means  generally  adopted  for  applying  this  substance  are  ineffi- 
cient. If  a  straight  stick  of  lunar  caustic  be  fixed  in  a  quill  or 
held  in  the  grasp  of  a  pair  of  forceps  and  passed  into  the  os,  by  no 
possibility  can  the  procedure  accomplish  what  is  desired.  It  may 
cauterize,  and  will  probably  do  so  with  objectionable  thoroughness, 
a  quarter  or  half  an  inch  of  the  lower  portion  of  the  canal,  but  how 
can  it  be  expected  to  go  upwards  for  an  inch  and  a  quarter  and 
come  in  contact  with  the  whole  surface  infiamed,  a  surface  remark- 
able for  its  inequalities  and  convolutions.  Sir  Benjamin  Brodie 
many  years  ago,  according  to  Dr.  Barnes,  of  London,  advised  fusing 
nitrate  of  silver  and  allowing  it  to  cool  upon  the  tip  of  a  probe  for 
cauterizing  sinuous  tracts,  and  Chassaignac,  of  Paris,  applied  the 
same  substance  to  the  cavity  of  the  womb  by  coating  platinum 
wires  with  it.  Within  the  last  few  years  Br.  F.  D.  Lente,  of  Cold 
Spring,  !N^.  Y.,  has  experimented  extensively  in  reference  to  this 
subject,  and  the  result  of  his  investigations  has  been  to  furnish  the 
profession  with  the  best  and  most  reliable  of  all  the  means  at  our 
command  for  applying  solid  lunar  caustic  to  the  mucous  lining  of 
the  uterus.  Othen methods  which  have  been  suggested  and  employed 
are  these:  the  use  of  Lallemand's  porte-caustique ;  leaving  a  pellet 
of  nitrate  of  silver  in  the  uterine  cavity  to  dissolve ;  carrying  up  a 
small  piece  held  in  a  delicate  wire  casing,  etc. ;  but  none  of  these 


250  CHRONIC    CERVICAL    ENDOMETRITIS. 

compare  with  Dr.  Lente's,  wliicli  is  thus  jDractised.  A  probe,  some- 
what similar  to  the  ordinary  uteriue  probe,  is  warmed  and  then 
dipped  in  a  little  platinum  cup  that  contains  nitrate  of  silver  whicli 
has  been  fused  over  a  spirit-lamp.  Removing  the  probe  after  dip- 
ping; it,  and  waving  it  for  a  few  seconds,  a  film  of  the  nitrate  will 
be  found  to  have  covered  its  tip.  It  may  then  be  again  dipped,  and 
the  process  repeated  until  a  sufficiently  large  pellet  is  made  to 
cover  the  end  of  the  instrument.  Figs.  71  and  72  represent  the 
probe  and  cup. 

Fig.  71. 


Lente's  silver  caustic  probe. 
Fig.  72. 


Lente's  cup  for  fusing  nitrate  of  silver. 

The  cervical  canal  having  been  cleansed  of  mucus,  and  its  direc- 
tion learned  by  the  ordinary  X)robe,  Lente's  probe  is  passed  up  and 
rubbed  against  every  part  of  its  investing  membrane,  and  dipped 
as  carefully  as  possible  into  its  convolutions  before  removal. 

After  such  an  application,  a  stream  of  water  should  be  jirojected 
against  the  cervix,  and  a  pledget  of  cotton,  which  has  been  freely 
saturated  with  glycerine,  with  a  bit  of  thread  attached,  should  be 
placed  against  it.  By  means  of  the  thread  this  may  be  removed  by 
the  patient  in  twelve  hours. 

The  walls  of  the  cervical  canal  may  also  be  thoroughly  cauterized 
by  the  introduction  and  retention  of  Braxton  Hicks'  crayons  of 
sulphate  of  copper,  iron,  zinc,  or  alum  cast  in  a  mould  of  the  length 
and  size  of  the  canal.  Those  which  I  have  seen  are  imported  from 
London.  They  are  introduced  into  the  cervical  canal  and  kept  in 
situ  by  a  roll  of  cotton.  The  zinc  points  may  be  allowed  to  dissolve, 
as  they  give  no  pain  in  doing  so.  Those  of  iron,  alum,  and  copper 
should  have  a  thread  attached  by  which  the  patient  may  remove 
them  when  they  cause  discomfort. 

Alteratives  in  combination  with  cocoa-butter  may  be  made  into 
suppositories  two  inches  in  length,  and  left  in  the  cervical  canal. 
Into  these  cervical  suppositories  may  be  introduced  zinc,  copper, 
iron,  lead,  or  bismuth,  with  opium,  conium,  or  hyoscyamus. 


DESTRUCTION    OR    ABLATION    OF    DISEASED    GLANDS.       251 

Fig.  73  represents  an  instrument,  originated  by  Dr.  Sims,  which 
consists  of  a  silver  probe  surmounted  by  a  slide,  by  means  of  which 
a  roll  of  cotton  soaked  in  any  medicated  solution  may  be  left  within 
the  cervical  canal. 

Fio-.  73. 


>^eWMMuMIII,mnlluh,,l,,ll,,ummniu,ih;,niM:,M^^^^^ 


Silver  probe  with  cotton  wrapped  around  it  and  thread  attached. 

Two  inches  of  the  probe  are  wrapped  with  cotton  which  is 
soaked  with  the  solution  selected  and  then  passed  into  the  cervical 
canal  so  as  to  be  engaged  within  the  os  internum.  The  roll  of 
medicated  cotton  is  then  slid  off  by  the  slide  and  retained  within 
the  canal,  while  the  probe  is  withdrawn.  In  twelve  hours  the 
patient  makes  traction  upon  the  thread  attached  to  the  cotton  and 
it  is  removed. 

Destruction  and  Ablation  of  the  Diseased  Glands. — As  every  gyne- 
cologist must  have  found  out  b}^  annoying  experience,  there  are 
cases  of  tliis  affection  which  prove  incurable  by  any  and  all  of  these 
means.  They  are  instances  not  of  granular  disease,  but  of  aggra- 
vated inflammation  of  the  mucous  follicles.  It  is  in  these  cases 
that  a  long,  glairy,  and  extremely  tenacious  plug  of  mucus  is  seen 
hanging  from  the  os  externum,  which  it  is  often  found  almost 
impossible  to  remove  completely.  Month  after  month  they  tax  the 
ingenuity  and  perseverance  of  the  practitioner,  and  at  the  end 
of  his  efforts  they  seem  as  aggravated  in  character  as  they  were 
before.  Under  these  circumstances  but  one  resource  remains,  that 
is  to  fulfil  the  indication  which  is  so  often  elsewhere  adopted  in 
surgery,  to  destroy  or  remove  the  habitat  of  a  disease  which  is 
not  susceptible  of  cure.  This  has  been  done  by  some,  by  the  use 
of  potassa  fusa  and  the  actual  cautery,  but  against  both  I  would 
strongly  advise,  for  they  produce  a  great  deal  of  subsequent  cica- 
tricial contraction.  Dr.  John  Byrne  informs  me  that  he  introduces 
with  good  effect  an  electrode  of  the  galvanic  cautery,  which  fits 
the  canal,  to  the  os  internum,  and  then  b}'  establishing  a  current 
makes  it  white  hot.     I  know  nothing  of  the  plan  personally. 

One  of  the  best  chemical  agents  for  destroying  the  glands  is 
fuming  nitric  acid.     This  should  be  carefully  applied  to  the  canal 


I 


252  CHRONIC    CERVICAL    ENDOMETRITIS. 

by  means  of  a  film  of  cotton  wrapped  around  the  silver  probe,  after 
the  canal  has  been  thoroughly  cleansed.  After  its  use,  a  stream  of 
cold  water  should  be  thrown  by  the  syringe  against  the  cervix  and 
a  wad  of  cotton  saturated  with  glycerine  applied.  In  ten  days  or  a 
fortnight  a  slough  of  the  cervical  mucous  membrane  will  take  place, 
after  which  the  surface  should  be  painted  over  twice  a  week  with 
a  solution  of  nitrate  of  silver  9j  to  water  ij. 

Another  good  caustic  is  a  saturated  solution  of  chromic  acid, 
which,  though  not  nearly  as  powerful  as  the  nitric  acid,  answers 
very  well. 

These  are  the  only  agents  which  I  would  recommend  for  this 
purpose.  ]^  itrate  of  silver  is  not  sufficiently  powerful,  and  potassa 
fusa  and  the  actual  cautery  are  too  destructive  in  their  results. 

In  alluding  to  these  cases  Dr.  West^  says,  "  I  am  disposed  to 
think,  however,  that  in  the  most  obstinate  cases  it  may  be  expe- 
dient to  adopt  a  suggestion  of  M.  Huguier,  of  which  I  have  but 
small  experience,  though  I  have  followed  it  Avith  benefit  on  two  or 
three  occasions.  He  is  accustomed  to  scarify  the  interior  of  the 
cervical  canal  with  a  small,  curved,  narrow-bladed,  blunt-pointed 
bistoury  before  introducing  the  caustic.  Tlie  jirevious  scarification 
exposes  the  more  deep  seated  follicles,  which  would  otherwise  alto- 
gether escape  tlie  action  of  the  remedy ;  and  Mdiile  M.  Huguier 
states  that  he  has  never  known  any  mischief  follow  this  proceed- 
ing, he  has  by  its  repetition  two  or  three  times  effected  the  cure  of 
cases  that  resisted  every  other  mode  of  treatment." 

In  these  very  obstinate  cases  I  have  repeatedly  resorted  to  a  sur- 
gical procedure  which  accomplishes  the  removal  of  these  glands, 
and  which  I  have  never  seen  followed  by  subsequent  contraction 
or  inflammation. 

This  consists  in  the  application  of  the  cutting  steel  curette,  rep- 
resented in  Fig.  74,  so  forcibly  as  to  remove  the  arbor  vitse  and 

Fig.  74. 


5s  -  -  ' 

Sims's  curette,  representing  the  angles  at  whicli  it  may  be  bent. 
'  "West,  op.  cit. 


DESTRUCTION    OR    ABLATION    OF    DISEASED    GLANDS.      253 

mucous  glands  from  the  os  internum  to  the  os  externum. 
Sometimes  a  second  operation  in  two  or  three  weeks  after  the  first 
has  heen  necessary,  and  very  rarely  even  a  third.  By  this  means 
I  have  succeeded  in  curing  some  most  obstinate  cases  which  had 
resisted  cure  by  all  other  means  except  the  destructive  caustics  to 
which  I  have  alluded.  The  use  of  this  method  should  be  looked 
upon  as  an  operation,  and  the  patient  guarded  just  as  carefullj- 
against  inflammation  as  she  would  be  after  section  of  the  neck  or 
any  kindred  procedure.  I  am  tn]\y  aware  that  there  are  nvduj 
who  will  at  once  characterize  this  procedure  as  harsh  and  unneces- 
sary, but  as  I  feel  certain  that  it  is  neither,  and  as  I  have  had  expe- 
rience enough  with  it  to  know  that  it  meets  the  requirements  of  a 
class  of  cases  which  are  incurable  by  other  means,  I  strongly  press 
its  claims  to  a  fair  trial.  This  operation  is  not  parallel  with  the 
application  of  the  curette  to  the  body  of  the  uterus  for  vegetations. 
It  consists  in  what  is  equivalent  to  amputation  of  the  glands,  and 
is  the  counterpart  of  removal  of  the  follicular  surfaces  of  the  tonsils 
when  chronic  inflammation  of  the  follicles  proves  incurable. 


254 


CHEOiSriC    CORPOREAL    ENDOMETRITIS. 


CHAPTER    XV. 


CHRONIC  CORPOREAL  ENDOMETRITIS. 


Like  the  cervix,  the  bod}^  of  the  uterus  is  liable  to  chronic  in- 
flammation conlined  to  its  lining  mucous  membrane.  This  receives 
the  name  of  chronic  corporeal  endometritis. 

Synonyms. — This  disease  has  been  described  under  the  names  of 
endometritis,  uterine  catarrh,  uterine  leucorrhcea,  and  internal 
metritis.     The  precise  seat  of  the  affection  is  pointed  out  by  the 


dots  in  Fig.  75. 


Fi^.  75. 


The  dots  show  the  site  of  corporeal  endometritis. 


Frequency. — Few  points  in  uterine  pathology  liave  created  more 
discussion  of  late  years  than  this.  Some  excellent  authorities,  fol- 
loAving  the  lead  of  Dr.  Henry  Bennet,  regard  it  as  of  rare  occur- 
rence, while  a  large  majority  consider  it  quite  common.  "  Internal 
metritis,"!  says  Aran,  "  is  more  frequent,  nevertheless,  in  spite  of 


'  Mai.  de  I'Ulerus,  p.  408. 


ANATOMY.  255 

all  that  has  been  said  to  the  contrary,  in  the  cavity  of  the  body 
than  in  the  cavity  of  the  neck  of  the  womb ;"  and  tliis  opinion  is 
concurred  in  by  Dr.  West  and  otliers.  To  show  how  unsettled  this 
point  is  in  tlie  ];)resent  state  of  pathology,  let  me  contrast  with  this 
statement  that  of  Prof.  Byford,^  of  Chicago,  in  his  excellent  work 
on  Medical  and  Surgical  Treatment  of  AVomen :  "  Inilammation 
limited  to  the  cavity  of  the  body  of  the  uterus  is  not  common, 
but  I  am  quite  sure  that  I  have  met  with  at  least  two  instances." 
AVhile  Dr.  By  ford's  experience  furnishes  him  but  two  instances, 
Dr.  Tilt  gives  the  statistics  of  iifty  cases  of  which  he  has  kept  notes, 
and  Klob  declares  the  disease  to  be  quite  conmion. 

The  more  industriously  the  student  of  gynecology  interrogates 
the  literature  of  this  subject,  the  more  unsettled  are  his  conclu- 
sions likely  to  be,  and  unfortunately  his  own  investigations,  how- 
ever carefully  conducted,  will  often  fail  to  enlighten  him  in  the 
individual  cases  with  which  he  meets,  for  the  differential  diag- 
nosis between  cervical  and  corporeal  endometritis  is  often  very 
difficult.  My  own  opinions  upon  this  important  point  I  shall 
state  freely,  unbiassed  by  those  of  authors  for  whom  I  entertain 
the  highest  respect,  but  whose  conclusions  conflict  with  what  I 
have  carefully  ol)servcd  at  the  bedside. 

The  most  frequent  locality  of  uterine  inflammation  is  that  por- 
tion of  the  uterus  below  a  line  running  across  it  through  the  os 
internum.  The  portion  of  the  organ  above  this  line,  however,  is 
much  more  commonly  afl'ected  by  inflammatory  disease  than  is 
stated  by  Dr.  Bennet.  During  eighteen  months  I  met,  in  private 
practice  alone,  nine  well-marked  and  unquestionable  cases,  and 
with  several  more  in  which  I  could  not  satisfy  myself  as  to  the 
exact  limit  of  the  disease.  The  lining  membrane  of  body  and 
cervix  may  be  simultaneously  afl'ected,  but  this  is  the  exception 
and  not  the  rule ;  generally  we  find  one  or  other  portion  of  the 
organ  the  seat  of  disease.  In  making  this  last  assertion  I  am  fully 
aware  of  its  importance,  and  of  the  fact  that  it  will  be  dissented 
from  by  a  great  many.  But  feeling  convinced,  as  I  do,  that  upon 
its  non-recognition  depends  a  certain  amount  of  the  obscurity 
attending  the  diflferentiation  of  disease  of  the  neck  and  body,  I 
wish  to  fix  the  attention  of  the  reader  upon  it. 

Anatomy. — If  the  mucous  membrane  of  the  uterus  be  examined 
with  a  lens,  it  will  be  seen  to  be  studded  with  minute  openings 

'  Op.  cit.,  p.  182. 


266  CHKONIC    CORPOREAL    ENDOMETRITIS. 

somewhat  similar  to  the  mouths  of  the  glands  of  Lieherkuhn  in 
the  intestines.  These  are  the  mouths  of  long,  curling  follicles, 
which  project  by  their  closed  extremities  downwards  towards  the 
parenchyma  of  the  organ.  They  are  lined  by  delicate  epithelium, 
their  lining  membrane  consisting  merely  of  involution  of  that  of 
the  uterus.  These  glands  are  of  two  kinds,  the  simple  which  are 
unbranched  tubes,  and  the  compound  which  have  several  branches. 
Besides  these  glands  there  are  intermixed  with  them  mucous  crypts, 
which  sometimes  become  distended  so  as  to  form  the  so-called 
''  channel  polypus." 

Between  these  glands  ramify  numerous  capillaries,  which  dip 
down  between  them  and  form  a  network  about  their  mouths  so 
superficial  that  they  are  sometimes  seen  by  a  strong  glass  com- 
pletely uncovered,  and  even  projecting  like  villi  into  the  cavity. 

Pathology. — Corporeal  endometritis  is,  like  the  same  aft'ection 
in  the  cervix,  a  glandular  disease.  The  utricular  follicles  are  the 
scat  of  the  disorder,  and  it  is  to  the  exaggeration  of  their  secretory 
function  that  is  due  the  uterine  leucorrhcea  which  constitutes  one 
of  its  prominent  symptoms. 

The  post-mortem  appearances  of  the  mucous  membrane  are 
these:  it  is  found  to  be  swollen,  soft,  pale,  and  smooth,  or  covered 
over  with  granulations.  In  cases  which  have  lasted  very  long  the 
utricular  glands  are  in  great  numbers  obliterated,  or,  atroi)hy  hav- 
ing taken  place  at  their  mouths  only,  their  secretions  are  retained, 
and  they  are  distended  into  cysts.  In  time  the  mucous  membrane 
is  replaced  by  a  thin  layer  of  connective  tissue,  which  is  covered 
not  by  cylindrical  or  ciliated  epithelium,  but  by  what  resembles 
that  of  basement  character.  At  times  small  mucous  polypi  are 
found  in  the  cavity,  while  at  others,  a  closure  of  the  os  internum 
uteri  having  been  eftected  by  adhesion,  hydrometra  exists. 

I  have  had  three  opportunities  for  examining  post  mortem  into 
the  pathology  of  this  disease.  Two  of  these  cases  were  presented 
to  the  Obstetrical  Society  of  this  city.  In  these  instances  the  con- 
dition described  by  Scanzoni  was  most  evident.  The  uterine  cavit}' 
was  found  considerably  enlarged,  its  walls  diminished  in  thickness, 
and  in  one  instance  they  were  pronounced  by  Dr.  J.  B.  Reynolds, 
after  microscopical  examination,  to  be  in  a  state  of  fatty  degenera- 
tion. The  uterine  neck  w^as  in  every  case  found  healthy  both  as 
to  parenchymatous  and  mucous  structure,  and  the  enlarged  body 
displaced  by  anterior  or  posterior  flexure.  The  mucous  lining  of 
the  body  was  in  two  cases  quite  smooth  and  to  a  great  extent 


PKEDISPOSIXG    CAUSES.  257 

dei^rived  of  epithelium,  while  in  the  third  it  was  roughened,  and 
presented  points  wliere  the  enlarged  bloodvessels  created  a  number 
of  reddish  spots.  But  enlargement  of  the  uterine  cavity  is  not 
always  present ;  it  marks  chronic  cases,  and  will  not  be  recognized 
in  those  of  recent  origin.  It  is  highly  probable,  too,  that  in  cases 
of  recent  origin  the  pathological  appearances  which  have  been 
here  described  would  not  be  found  to  exist,  but  in  [)lace  of  them 
a  thickened,  congested,  and  florid  appearance  would  present  itself. 

Prognosis. — The  prognosis  of  chronic  inflammation  of  the  uterine 
body  is  always  grave  with  reference  to  cure.  Even  if  the  case  be 
not  of  very  serious  character,  and  have  lasted  onlya  short  time,  the 
possibility  of  rapid  recovery  is  doubtful,  while,  if  it  have  continued 
for  a  number  of  years,  it  will  often  prove  incurable.  Scanzoni^ 
says,  with  a  candor  which  does  him  honor:  "As  for  ourselves  we 
do  not  remember  a  single  case  where  we  have  been  able  to  cure 
an  abundant  uterine  leucorrhoca  of  several  years'  standing."  In 
most  cases  a  certain  amount  of  amelioration  may  be  cftected  even 
when  they  are  of  long  standing;  in  a  certain  number  treated  early, 
cure  may  unquestionablj'  be  accomplished  ;  while  in  a  great  many, 
nothing  whatever,  either  in  the  way  of  cure  or  of  relief,  can  be  ob- 
tained, and  the  patient,  after  passing  from  physician  to  phj-sician, 
settles  down  into  a  careful  mode  of  life,  resolved  to  cease  treatment 
and  bear  as  best  she  may  an  evil  which  she  has  learned  to  regard 
as  incurable. 

The  s^miptoms  of  a  favorable  and  unfavorable  case  of  corporeal 
endometritis  may  be  thus  contrasted: 


Prognosis  is  Favorable  when 
The  case  is  of  recent  standing; 
The  discharge  is  of  mucus  or  blood; 
Dysmenorrhoeal  shreds  are  not  cast  off; 
Patient  naturally  of  strong  constitution; 
Connective  tissue  is  nut  affected; 
No  displacement  exists; 
Dimensions  of  cavity  are  not  increased ; 
Nervous  system  is  not  involved; 
I'atient  near  menopause. 


Prognosis  is  Unfavorable  when 
The  case  is  of  long  standing; 
The  discharge  is  purulent; 
Dysmenorrhoeal  shreds  are  cast  off; 
Patient  naturally  of  feeble  constitution  ; 
Connective  tissue  is  affected ; 
Displacement  exists ; 
Dimensions  of  cavity  are  increased ; 
Nervous  system  is  involved; 
Patient  not  near  menopause. 


Predisposing  Causes. — It  has  been  noticed  most  frequently  to 
have  developed  itself  in  women  showing  a  tendency  to  the  follow- 
ing conditions: 

'  Scanzoni,  Diseases  of  Females,  Am.  ed.,  p.  202. 

17 


258  CHRONIC    CORPOREAL    ENDOMETRITIS. 

Scrofula ; 

Tuberculosis ; 

Spansemia ; 

Exhaustion  from  parturition ; 

Exhaustion  from  lactation ; 

Great  and  prolonged  nervous  depression. 

Exciting  Causes. — These  may  be  enumerated  as  follows: 

Exposure  during  menstruation ; 

Sudden  checking  of  the  menstrual  flow ; 

Obstruction  to  escope  of  menstrual  blood  ; 

Abortion  and  parturition; 

Cervical  endometritis; 

Acute  endometritis,  puerperal  or  not ; 

Subinvolution; 

Displacements  causing  great  congestion ; 

Chronic  pelvic  peritonitis; 

Abuse  of  sexual  intercourse; 

Injury  from  sounds,  or  intra-uterine  pessaries,  and   injuries 

resulting  from  attempts  to  produce  abortion ; 
Certain  hemic  conditions,  as  those  accompanying  phthisis  and 

the  exanthematous  diseases ; 
Tumors  in  the  uterine  cavity  or  walls ; 
Vaginitis,  specific  or  simple. 

It  is  quite  clear  how  either  of  the  first  two  causes,  in  checking 
hemorrhage  from  the  congested  mucous  lining  of  the  uterine  body, 
may  at  once  induce  the  first  stage  of  this  disease.  They  generally 
result  in  the  acute  variety,  which  passes  off  rapidly,  but  which 
sometimes  ends  in  the  chronic  form. 

Obstruction  to  escape  of  menstrual  blood  is  a  very  fruitful  source 
of  the  affection.  The  menstrual  blood,  if  it  pour  at  once  into  the 
vagina,  remains  fluid  from  admixture  of  an  acid  mucus  secreted  by 
the  lining  membrane  of  that  canal;  but  if  it  be  imprisoned  in  the 
uterine  cavity,  where  only  an  alkaline  mucus  exists,  it  very  soon 
becomes  clotted.  These  clots  are  too  large  to  pass  through  a  cervix 
of  normal  dimensions,  and,  of  course,  cannot  escape  from  one 
unnaturally  constricted.  Their  presence  in  the  uterine  cavity, 
together  with  that  of  blood  which  they  imprison,  in  time  excites 
contraction,  by  which  they  are  expelled.  This  repeated  dilata- 
tion and  contraction  cannot  last  long  without  exciting  inflamma- 


EXCITING    CAUSES.  259 

tion  in  the  mucous  membrane  of  the  uterus.  Such  an  obstruction 
may  have  as  its  cause  a  small  polypus,  which  acts  as  a  ball  valve 
at  the  OS  internum,  congenital  or  acquired  narrowness  of  the  cervi- 
cal canal,  or  uterine  flexion. 

The  parturient  process  is  a  very  frequent  source  of  the  disease, 
especially  wliere  the  undeveloped  placenta  is  prematurely  separated 
from  its  uterine  connection.  Where,  in  a  prolonged  labor,  the  early 
evacuation  of  the  liquor  amnii  leaves  the  irregular  outline  of  the 
body  of  the  child  pressing  against  the  uterine  investment  for  many 
hours,  such  a  sequel  might  result. 

Of  cervical  inflammation  as  an  exciting  cause  Dr.  Bennet^  thus 
expresses  himself:  "It,"  (corporeal  endometritis,)  "api)ears,  how- 
ever, to  be  generally  met  with  in  practice  as  the  result  of  the 
lengthened  existence  of  inflammatory  disease  of  the  cervix  and  its 
cavities.  The  inflammation  gradually  progresses  along  the  cavity 
of  the  cervix  until  it  reaches  the  os  internum,  and  passes  into  the 
uterus."  I  have  already  stated  my  dissent  from  this  view,  although, 
at  the  same  time,  I  admit  that  it  may  be  correct. 

Acute  endometritis  may,  instead  of  subsiding  entirely,  very 
naturally  run  into  this  disease. 

Subinvolution  of  the  uterus  keeps  up  a  constant  tendency  to 
hypersemia  of  the  parenchyma  wliich  affects  the  mucous  membrane. 
As  a  complication  of  this  condition  corporeal  endometritis  is  more 
commonly  observed  than  as  a  consequence  of  all  the  other  causes 
combined. 

Pelvic  peritonitis  disturbs  the  position,  the  innervation,  and  the 
circulation  of  the  uterus,  and  proves  a  fruitful  source  of  endometritis. 

The  effect  of  sexual  intercourse  as  a  causative  influence  is 
frequently  observed  soon  after  marriage,  the  first  connul)ial  ap- 
proaches exciting  uterine  congestion  with  greater  or  less  intensity. 
Dr.  Tilt^  remarks  with  reference  to  it :  "  It  is  useless  to  disguise 
the  fact,  connection  has  a  downright  poisonous  influence  on  the 
generative  organs  of  some  women."  I  cannot  believe  that  the 
Almighty  has  ordained  a  function  as  essential  to  the  perpetuation 
of  our  species  which  has  a  downright  poisonous  influence  on  the 
generative  organs  of  a  healthy  woman.  And  yet,  to  a  certain 
extent,  the  statement  is  correct,  for  upon  a  woman  who  has  en- 
feebled her  system  by  habits  of  indolence  and  luxury,  pressed  her 
uterus  entirely  out  of  its  normal  place,  and  perhaps  goes  to  the 

'  Op.  cit.,  p.  75.  2  Op.  cit,  p.  234. 


260  CHRONIC    CORPOREAL    ENDOMETRITIS. 

nuptial  bed  with  some  lurking  uterine  disorder,  the  result  of 
imiDrudence  at  menstrual  epochs,  sexual  intercourse  has  indeed 
such  an  influence.  The  taking  of  food  into  the  stomach  exerts  no 
injurious  influence  on  the  digestive  system,  but  the  taking  of  food 
by  a  dyspeptic  who  has  abused  and  injured  the  organ,  may  do  so. 

Injuries  from  sounds,  etc.,  act  so  evidently  in  exciting  inflamma- 
tion as  to  need  only  mention. 

Certain  conditions  of  the  blood  sometimes  produce  acute  cor- 
poreal endometritis,  which,  as  already  stated,  may  pass  into  tlie 
form  under  consideration.  As  a  complication  of  the  exanthema- 
tous  diseases,  endometritis  is  well  known,  and  its  occurrence  with 
phthisis  has  been  noted  by  Dr.  Gardner  in  the  American  edition  of 
Scanzoni.  Every  practitioner  must  have  noticed  it  in  connection 
with  that  afll'ction. 

Tumors  in  the  cavity  or  walls  of  the  uterus  very  generally  pro- 
duce this  disease  in  consequence  of  the  congestion  of  the  mucous 
membrane  which  they  cause. 

Vaginitis  of  non-specific  character  may,  and  of  specific  form 
often  does,  pass  by  continuity  of  structure  into  the  neck  and  body 
of  the  uterus.  The  latter  has  in  these  cases  in  my  experience 
not  only  afiected  the  body,  but  the  Fallopian  tubes,  resulting  in 
peritonitis. 

Symptoms. — The  symptomatology  of  corporeal  endometritis  con- 
stitutes one  of  the  most  unsatisfactory  and  obscure  subjects  in  the 
entire  field  of  gynecology.  At  times  its  symptoms  are  so  slight 
and  at  others  so  masked  and  obscure,  that  the  disease  often  runs  a 
lengthy  course  without  exciting  the  suspicions  of  either  ])hysician 
or  patient.  Its  effects  upon  the  constitution  also  difler  most 
unaccountably  in  different  cases.  Sometimes  the  disease  will 
continue  for  ten,  fifteen,  or  twent}'  years,  producing  profuse  leu- 
corrhffia,  menstrual  disorders,  and  nervous  derangement,  and  yet 
result  in  no  annoyance  so  grave  as  to  cause  the  patient  to  seek 
medical  aid.  At  others  it  accompanies  or  excites  areolar  hyper- 
plasia, which  induces  displacement  and  causes  pain  on  locomotion, 
sexual  intercourse,  and  the  passas^e  of  feces  through  the  rectum  ; 
or  results  in  an  ichorous  discharge,  Avhieh  creates  the  annoying 
symptoms  of  vaginitis,  cystitis,  or  pruritus  vulvae.  The  chief 
symptoms  which  usually  present  themselves  in  a  case  of  mucous 
inflammation  of  the  uterine  body  are: 

Leucorrhoea ; 
Menstrual  disorders; 


SYMPTOMS.  261 

Pain  in  the  back,  groins,  and  hypogastrium ; 

^Nervous  disorders ; 

Tympanites ; 

Symptoms  of  pregnancy ;  i 

Sterility-. 

Profuse  leucorrhcea  of  glair}'^  character  is  one  of  the  chief  signs 
of  the  aliection.  This  when  very  tenacious  and  thick  is  the 
product  of  the  cervical  glands,  but  the  lining  membrane  of  the 
uterus  likewise  secretes  a  similar  fluid,  diftering  from  it  chiefly  in 
possessing  the  qualities  mentioned  in  a  very  much  less  marked 
degree.  But  uterine  leucorrhcea  differs  from  cervical  in  other 
particulars ;  it  is  often  more  or  less  mixed  with  blood  so  as  to  have 
a  rust-colored  appearance,  especially  for  a  fortnight  after  menstru- 
ation. This,  Dr.  Bennet'  looks  upon  as  being  "  as  characteristic 
of  internal  metritis  as  the  rust-colored  expectoration  is  of  pneu- 
monia." It  is  a  reliable  and  valuable,  though  by  no  means  a  Uni- 
versal, sign.  Sometimes  the  menstrual  discharge  is  regarded  by 
the  patient  as  greatly  prolonged,  when  in  reality  it  is  this  blood- 
stained leucorrhcea  which  follows  the  process  of  menstruation,  that 
gives  rise  to  the  belief.  In  some  instances  the  discharge  is  milky, 
and  at  others,  and  these  are  the  most  rebellious  cases,  perfectly 
purulent.  There  is  a  variety  of  corporeal  endometritis  which 
occurs  in  old  women  who  have  long  ceased  to  menstruate,  in 
which  a  watery  or  creamy  pus  is  secreted.  These  cases  are 
often  accompanied  by  the  most  wearing  and  harassing  pruritus 
vulvae. 

Menstrual  disorders  are  rarely  absent.  The  discharge  is  some- 
times too  profuse,  even  lasting  throughout  the  month  and  consti- 
tuting metrorrhagia,  or  it  is  very  scanty,  and  shows  a  marked 
tendency  to  cessation. 

Where  the  connective  tissue  is  entirely  unaflfected,  menorrhagia 
may  occur  without  pain,  but  this  is  not  common,  for  that  tissue  is 
often  simultaneously  involved  and  dysmenorrhoea  coexists.  Some- 
times in  these  cases,  an  exfoliation  of  the  entire  lining  membrane 
of  the  cavity  of  the  uterine  body  occurs  at  the  menstrual  periods. 
This  has  received  the  name  of  the  dysmenorrhoeal  membrane,  and 
is  by  some  regarded  as  an  evidence  of  chronic  corporeal  endo- 
metritis. 

Pain  in  the  back,  groins,  and  hypogastrium  is  generally  present, 

'  Op.  cit.,  p.  76. 


262  CHRONIC    CORPOREAL    ENDOMETRITIS. 

and  at  times  a  burning  sensation  over  the  symphysis  pubis  proves 
a  source  of  great  discomfort. 

Is^ervous  symptoms  of  greater  or  less  severity  generally  show 
themselves  before  the  disease  has  lasted  long.  The  patient  com- 
plains of  neuralgic  headache,  especially  over  the  crown,  hysterical 
symptoms,  with  sadness,  tendency  to  weep,  and  a  feeling  of  intense 
isolation  and  incapacity  for  any  mental  effort. 

Meteorism  is  a  very  common  symptom,  the  connection  of  which 
with  inflammation  of  the  uterine  mucous  membrane  is  not,  at  first 
glance,  clear.  It  is  probably  due  to  disorder  of  the  nervous  influ- 
ences governing  peristalsis  and  giving  tone  to  the  intestinal  mus- 
cular tissue,  which  proceeds  to  such  an  extent  as  to  result  in  accu- 
mulation of  gases  in  the  canal.  In  the  same  way  this  affection 
may  induce  constipation,  which  is  often  one  of  its  most  obstinate 
accompaniments. 

Symptoms  of  pregnancy  often  exist  in  connection  with  the  dis- 
ease, and  sometimes  mislead  the  physician.  !N"ausea  and  vomiting 
are  by  no  means  invariably  present,  but  are  valuable  signs.  They 
appear  to  result  from  this  disease  as  they  do  from  occupation  of  the 
uterine  cavity  by  the  product  of  conception.  Sometimes,  in  addi- 
tion to  these,  there  are  darkening  of  the  areolae  of  the  breasts,  and 
enlargement  and  sensitiveness  of  the  mammary  glands.  When  to 
these  are  added  abdominal  enlargement,  from  tympanites  and  irre- 
gularity of  menstruation,  it  will  be  perceived  how  easily  an  error 
might  be  made. 

Sterility  is  so  commonly  a  result  of  endometritis  that  it  should 
be  considered  as  one  of  its  signs.  Very  often  it  has  been  the  only 
symptom  that  has  led  to  an  investigation  of  the  state  of  the  uterus 
which  has  determined  the  existence  of  the  disease.  The  affection 
does  not,  however,  preclude  the  possibility  of  conception ;  it  only 
diminishes  the  probability. 

Physical  Signs. — The  physical  signs  are  neither  numerous  nor 
reliable.  Those  of  real  value  only  will  be  mentioned.  The  uterine 
probe  passed  into  the  cavity  will  often  show  the  length  of  the 
uterus  to  be  greater  than  it  would  be  in  health,  and  create  more 
discomfort  than  in  a  healthy  uterus.  Upon  conjoined  manipu- 
lation, two  fingers  being  placed  in  the  fornix  vaginae,  and  the 
fingers  of  the  other  hand  made  to  depress  the  anterior  wall  of  the 
abdomen,  sensitiveness  will  usually  be  found  in  the  body  of  the 
organ.  The  recognition  of  the  absence  of  cervical  disease,  while 
at  the  same  time  there  are  profuse  uterine   leucorrhoea  and  the 


TREATMENT.  263 

other  symptoms  recorded-,  will  lead  us  strongly  to  suspect  corpo- 
real endometritis.  Lastly,  dilatation  of  the  os  internum  may  be 
taken  as  a  corroborative  sign. 

Course^  Duration.,  and  Termination. — This  disorder  often  lasts  for 
years ;  in  the  case  of  a  multiparous  woman  confining  itself  to  the 
mucous  membrane ;  in  that  of  a  woman  who  has  borne  children 
gradually  exciting  congestion  and  exuberant  growth  in  the  sub- 
jacent parenchyma.  This  is  the  most  frequent  result  exerted  upon 
the  parenchyma,  but  it  may  be  aftected  in  two  waj'S :  1st,  a  hyper- 
plasia, or  excess  of  nutrition,  may  occur;  2d,  an  aplasia,  or  want 
of  nutrition,  may  take  place,  and  dilatation  and  distention  event- 
uate. 

Complications. — The  most  ordinary  complications  met  with  are 
displacement,  vaginitis,  granular  degeneration  of  the  cervix,  and 
pruritus  vulvae. 

Treatment. — Special  attention  should  be  given  to  sustaining  and 
improving  the  general  health  of  the  patient,  which  will  often 
show  a  marked  tendency  to  depreciation.  Good  diet,  fresh  air, 
systematic  exercise,  and  avoidance  of  all  circumstances  calculated 
to  depress  the  spirits  or  harass  the  mind,  should  be  recommended. 
If  practicable,  change  of  air  and  scene  should  be  brought  to  our 
aid,  and  the  patient  be  sent  occasionally  to  some  suitable  watering- 
place  or  country  resort.  The  healthy  condition  of  the  nervous  and 
sanguineous  systems  will  be  fostered  by  these  measures,  and  should 
medicinal  tonics  be  required,  iron,  the  mineral  acids,  quinine,  the 
bromide  of  potassium,  or  nux  vomica  may  be  administered.  All 
rich  and  highly  spiced  food  should  be  avoided,  and  the  patient 
should  be  guarded  against  habits  of  indolence  and  luxury  which 
tend  to  exhaust  the  nervous  strength. 

The  uterus  should  be  placed  at  rest  by  removal  of  pressure  upon 
the  fundus  by  clothing,  limitation  of  marital  intercourse,  avoidance 
of  violent  and  intemperate  exercise,  and  if  necessary,  by  a  sustain- 
ing pessary. 

The  part  affected  being  removed  from  the  vagina  on  the  one 
hand,  and  the  pelvic  and  abdominal  walls  on  the  other,  little  ad- 
vantage results  from  the  emollient  applications  and  depletory 
means  which  prove  useful  where  the  cervix  is  diseased.  Our  chief 
hope  of  affording  relief  must  rest  upon  the  general  measures  just 
mentioned,  and  upon  the  direct  application  to  the  diseased  surface 
of  alterative  remedies. 

Application  of  Alteratives. — Recamier  was  the  first  who  had  the 


264 


CHRONIC    CORPOREAL    ENDOMETRITIS. 


Fiff.  76. 


boldness  to  cauterize  the  cavity  of  the-  uterus,  which  he  did  by 
means  of  nitrate  of  silver  in  an  ordinary  porte-eaustique.  The 
practice  thus  introduced  was  continued  and  spread  abroad  by 
Robert,  Richet,  Trousseau,  Maisonneuve,  and  others,  and  to-day 
is  still  resorted  to  for  combating  this  rebellious  affection.  There 
are  four  methods  by  which  it  may  be  practised :  1st,  by  the  use 
of  solutions  painted  over  the  surface ;  2d,  by 
ointments  left  to  melt  in  utero ;  3d,  by  injec- 
tions of  fluids  into  the  cavity  of  the  body ; 
4th,  by  solid  caustics.  In  commencing  treat- 
ment the  practitioner  should  see  that  the  cer- 
vical canal  is  well  opened,  in  order  to  admit 
the  free  escape  of  fluids  from  the  cavity  above, 
and  the  application  of  substances  through  it 
from  below.  This  perviousness,  if  it  do  not 
exist,  should  be  secured  by  the  use  of  dila- 
tors before  the  local  treatment  is  proceeded 
with.  If  the  uterus  be  found  sensitive  to  vaginal 
and  rectal  touch,  the  patient  should  remain  in 
bed  for  some  days  before  the  first' application  is 
made,  the  bowels  be  kept  active  by  mild  saline 
purgatives,  and  warm  l)aths  or  hip-baths  with 
copious  vaginal  injections  employed.  If  the 
operator  use  the  ordinary  long,  cylindrical 
speculum,  he  will  in  the  majority  of  cases  fail 
to  accomplish  the  end  in  view,  reaching  the 
fundus  uteri,  for  through  such  an  instrument, 
it  is  always  diflicult  to  penetrate  so  high  into 
the  cavity.  If,  however,  he  use  the  Sims 
speculum,  or  one  of  its  modifications,  or  a 
short,  cylindrical  instrument,  he  will  succeed 
without  eftbrt  or  delay.  The  instrument  be- 
ing introduced  and  the  cervix  cleansed  by 
the  speculum  syringe,  the  operator  very  gently 
passes  through  the  cervical  canal  a  small  and 
delicate  cervical  speculum.  That  shown  in 
Fig.  76  is  one  of  the  best  of  its  kind. 

Having  previously  wrapped  the  silver  or  hard 
rubber  probe  with  a  film  of  cotton,  he  now  passes 

speluum,' witr^robe   *^^^^  ^^^  ^^  ^^®  fundus.  ^  This  removcs  a  good  deal 
passing  through  it.        of  niucus  from  the  cavity  which  would  otherwise 


USE    OF    OINTMENTS.  265 

have  neutralized  the  caustic  introduced.  Removing  the  cotton  from 
the  prohe  he  wraps  another  piece  around  it,  or,  as  is  better,  uses 
another  probe  ah'eady  wrapped,  and,  dipping  this  into  tlie  fluid 
caustic  which  he  has  determined  to  use,  he  passes  it  directly  to  the 
fundus  and  gently  moves  it  over  the  surface.  This  should  not  be 
repeated,  for  the  astringent  action  of  the  caustic  makes  repetition 
difficult,  and  if  properly  done  the  first  time  it  will  be  unnecessary. 
After  this  the  patient  should  go  to  bed  and  remain  perfectly  quiet, 
until  the  next  day  at  least,  and  if  any  discomfort  exist,  for  several 
days. 

In  place  of  the  cotton-wrapped  probe,  the  painting  of  the  uterine 
surface  may  be  very  thoroughly  accomplished  by  the  use  of  a  small 
brush  of  pig's  bristles  dipped  in  the  solution,  and  passed  through 
the  cervical  speculum. 

The  alteratives  which  may  be  thus  employed  are : 

Solution  of  chromic  acid  3j  to  3J  water  ; 

Solution  of  nitrate  of  silver  9j  or  ^ss  to  5J  of  water ; 

Compound  tincture  of  iodine  3ss  to  5SS  of  glycerine  ; 

Saturated  solution  of  sulphate  of  zinc  ; 

Saturated  solution  of  sulphate  of  copper  ; 

U.  S.  D.  solution  persulphate  or  perchloride  of  iron  with  equal  parts  of  glycerine  ; 

Solution  of  chloride  of  zinc  3j  to  3J  water  ; 

JJ.  S.  D.  muriate  tincture  of  iron  ^ij  to  5J  water; 

Saturated  solution  of  carbolic  acid. 

By  the  admixture  of  water,  glycerine,  or  alcohol,  these  solutions 
may  be  weakened  to  any  extent  desired.  I  would  advise  against  the 
use  of  strong  caustics  in  endometritis  occurring  above  the  os  inter- 
num, upon  the  ground  that  I  have  not  seen  them  accomplish  as 
much  good  as  the  same  substances  in  alterative  strength.  There 
are  certain  conditions  of  disease  in  this  jDart  resulting  from  chronic 
inflammation  for  which  I  shall  recommend  them,  but  these  are 
consequences  of  the  disease  and  not  the  disease  itself.  I  would  not 
in  the  condition  which  we  are  considering  employ  the  nitrate  of 
silver  in  solid  form,  pure  chromic  acid,  or  fuming  nitric  acid. 

Use  of  Oiniments. — The  application  of  ointments  to  the  lining 
membrane  of  the  uterus  is  so  inconvenient  and  disagreeable  a  pro- 
cess that  I  cannot  recommend  it.  It  possesses  no  special  advan- 
tages. It  is  proceeded  with  in  much  the  same  manner  as  that  of 
fluids,  except  that  a  different  instrument  is,  of  course,  necessary 
for  their  introduction.  One  which  answers  the  purpose  very  well 
is  the  invention  of  Dr.  F.  D.  Lente.  It  consists  of  a  syringe  with 
a  silver  tube  attached.     The  ointment  to  be  employed  is  put  into 


266  CHRONIC    COKPOREAL    ENDOMETRITIS. 

the  sja-inge  by  a  spatula,  and,  the  tube  being  introduced  into  the 
uterine  cavity,  the  piston  is  pushed  forward  and  the  ointment  is 
forced  out.  The  following  are  the  ointments  which  are  generally 
thus  employed,  though  any  others — as  lead,  bismuth,  calomel, 
iodine,  etc. — might  he  substituted : 

R. — Argenti  iiitratis,  ^ij  ; 
Belladonnae  ext.  3j  ; 
Uugt.  spermaceti,  5ij. — M. 

R. — Pluinbi  acet.  3ij  ; 

Morph.  sulphat.  gr.  iv ; 
Butyr.  cacao,  5ss; 
01.  olivae,  q.  s. — M. 

The  Application  of  Alteratives  of  Solid  Character  to  the  JEndometrium. 
— Substances  of  solid  character  wdiieh  will  melt  under  the  influence 
of  the  heat  of  the  body  may  be  introduced  into  the  uterine  cavity 
in  the  form  of  suppositories  or  pencils.  The  pencils  of  zinc,  copper, 
alum,  or  iron  mentioned  in  the  last  chapter  may  be  thus  employed, 
or  suppositories  made  with  cocoa-butter,  or  according  to  Becquerel's 
formula,  may  be  used  instead.  Becquerel's  formula  is  the  follow- 
ing: 

R. — Tannin,  4  parts  ; 

Gum  tragacanth,  1  part ; 
Bread  crumb,  q.  s. 
One  to  be  gently  pushed  into  the  uterine  cavity  and  allowed  to  melt,  every  four 
days. 

Upon  first  trying  an  intra-uterine  suppository  or  pencil  of  a 
certain  strength,  I  should  advise  that  a  thread  should  always  be 
attached  to  it  in  order  that  it  may  be  removed  by  the  patient  in 
case  of  pain.  After  testing  in  this  w^ay,  the  thread  may  be  dis- 
pensed with,  but,  as  a  preliminary  precaution,  its  necessity  is  great. 
Cases  are  met  with  in  wdiich  a  few  drops  of  water  in  the  cavity  of 
the  uterus  will  cause  pain,  and  I  have  seen  the  cautious  introduc- 
tion of  the  uterine  sound  cause  violent  epileptiform  convulsions. 
Should  such  a  result  follow  the  introduction  of  a  medicated  pencil 
which  has  slipped  out  of  reach,  the  position  of  the  introducer 
would  be  an  unfortunate  one. 

Injections  into  the  Uterine  Cavity. — The  subject  of  intra-uterine 
injection  has  recently  come  very  prominently  before  the  profession, 
and  been  fully  and  ably  discussed.  Many  eminent  authorities  have 
pronounced  in  its  favor,  and  reported  hundreds  of  cases  in  which 
they  have  employed  it  with  impunity  and  benefit.    In  the  practices 


INJECTIONS    INTO    THE    UTERINE    CAVITY.  267 

of  many  it  is,  indeed,  a  routine  method  of  treating  corporeal  endo- 
metritis. While  the  evidence  which  has  been  adduced  proves  that 
with  proper  precautions  this  means  of  medication  is  robbed  of  its 
chief  dangers,  it  likewise  makes  it  evident  that  in  careless,  inex- 
perienced, or  unskilful  hands  it  carries  with  it  manifold  and  serious 
perils. 

This  method  of  treatment  is  not  a  new  one,  as  many  have 
appeared  to  think,  but  one  of  the  oldest  on  record.  It  is  certainly 
a  suspicious  circumstance  that,  employed,  as  it  has  been  at  various 
periods,  during  2200  yeai*s,  it  should  have,  even  at  our  day,  as 
many  opponents  as  it  now  numbers  arrayed  against  it.  It  may  be 
suggested  that  the  necessity  for  allowing  escape  of  the  injected 
fluid  has  been  only  recently  recognized,  and  that  therefore  the 
safety  of  the  method  has  been  only  of  late  secured;  but  this  is 
not  so,  for  in  1833,  Melier  of  France  employed  a  double  canula 
constructed  on  the  same  principle  as  that  of  some  to  which  I 
shall  soon  make  allusion.  In  this  connection  it  may  not  be 
unprofitable  to  take  a  rapid  survey  of  the  history  of  the  subject. 
For  most  of  my  facts  I  am  indebted  to  an  exhaustive  article  by 
Dr.  J.  Cohnhein*  of  Berlin,  and  translated  by  Dr.  Kammerer^  of 
this  city.  Intra-uterine  injections  were  employed  and  advised  by 
Hippocrates,  B.  C.  400,  for  the  purposes  of  washing  out  bits  of 
retained  placenta  and  medicating  the  surface  aftected  by  catarrh. 
They  are  likewise  advised  by  Paulus  -dEgineta,  and  as  we  come 
down  to  later  times,  by  Sylvius,  Montanus,  Ambrose  Pare,  Bot- 
toni,  Roderic  a  Castro,  Mercurialis,  Ludovic  Mercatus,  and  Astruc. 
Otto,  a  translator  of  Astruc  into  German,  in  a  note  ex])resses  the 
opinion  that  the  fluid  does  not  ordinarily  penetrate  into  the  uterine 
cavity,  being  prevented  by  the  os  internum,  and  says  that  "he 
knows  of  cases  in  which  the  use  of  the  above  'beautiful  remedies' 
was  followed  by  attacks  of  severe  uterine  colic."  The  method  was 
again  advised  by  Wenceslaus,  CoUingwood,  Berends,  and  Stein- 
burger,  and  opposed  with  apparently  equal  warmth  by  Frank  and 
Hourmann.  The  latter  author  drew  attention  to  the  dangers  of 
the  method  by  reporting  a  case  of  severe  metroperitonitis,  which 
resulted  from  a  simple  injection  given  for  leucorrhcea,  and  imme- 
diately following  his  case  three  fatal  ones  were  reported,  two  in 
Bretonneau's  wards  and  one  in  Nelaton's.     At  a  still  later  period 

'  Beitrage  zur  Therapie  der  Chronischen  Metritis.     Berlin,  1868. 
2  Amer.  Journ.  Obstet.,  vol.  i,  p.  377. 


i 


268  CHRONIC    CORPOREAL    ENDOMETRITIS. 

they  have  heen  recommended  by  Rccamier,  Velpeau,  Ricord,  Ken- 
nedy, Retzius,  Routh,  Sigminid,  Matthews  Duncan,  Tilt,  Braun, 
Martin,  Courty,  Nott,  Kammerer,  and  others,  and  been  opposed  by 
Oldham,  Mayer,  Bessems,  H.  Bennet,  Gosselin,  Depaul,  and  others. 
Cases  of  violent  uterine  colic,  accompanied  by  great  prostration, 
feeble  and  rapid  pulse,  faintness  and  coldness  of  extremities,  are 
repeatedly  recorded  even  by  the  advocates  of  the  method ;  and 
peritonitis,  ovaritis,  and  salpingitis,  which  have  been  recovered 
from,  have  been  met  with  as  results  of  the  practice  by  Hourmann, 
Leroi  d'Etiolles,  Landsberg,  Oldham,  Pedelaborde,  Retzius,  Bec- 
querel,  Noeggerath,  myself,  and  others.  Fatal  cases  of  peritonitis 
have  occurred  to  Bretonneau,  Nelaton,  Gubiau,  Noeggerath,  Von 
Haselberg,^  Jobert,^  and  others.  A  case  of  sudden  death  from 
entrance  of  air  into  the  veins  has  been  met  with  by  Bessems,^  who, 
in  post-mortem  examination,  "  found  air-bubbles  in  the  vena  cava 
and  heart."  Another  case  ending  thus  suddenly  is  reported  by 
Dr.  Warner,^  of  Boston,  as  occurring  at  the  Charity  IIos})ital  of 
St.  Louis,  where  "a  small  quantity  of  water  injected  into  the  uterus 
occasioned  immediately  death.  This  result  was  evidently  from 
shock."  I  do  not  find  any  statistical  records  from  Dr.  Simpson 
upon  the  subject,  but  the  general  impression  left  upon  his  mind 
concerning  the  method  is  thus  plainly  stated:'  "But,  mark  you, 
never  think  or  dream  of  throwing  liquids  into  the  interior  of  the 
uterus  by  means  of  any  injecting  apparatus,  for  severe  and  fatal 
inflammations  are  very  likely  to  ensue.  Such  a  result  may  perhaps 
be  caused  by  the  fluid  running  along  one  or  other  patent  Fallopian 
tube,  and  escaping  into  the  peritoneum ;  more  probably  it  may  be 
due  to  laceration  of  the  mucous  membrane  and  entrance  of  the 
fluid  into  one  of  the  uterine  veins;  but- however  it  may  be  pro- 
duced, the  consequences  of  injecting  fluid  into  the  cavity  of  the 
womb  are  so  often  dangerous  and  deadly,  that  the  practice  has  now 
been  given  up,  I  believe,  by  all  accoucheurs."  In  this  passage  he 
alludes  to  injections  into  the  non-jnierperal  uterus  for  dysmenor- 
rhoea.  BecquereP  reports  the  practice  as  applied  to  six  cases  of 
uterine  catarrh.  "In  one  case  only,  the  catarrh  was  diminished; 
of  the  remaining  five,  three  could  be  saved  only  by  energetic  anti- 


'  Amer.  Journ.  Med.  Sci.,  April,  1870,  p.  566. 

2  Beunet  on  the  Uterus,  p.  287. 

3  N.  Y.  Journ.  Obstet.,  vol.  i,  p.  394. 

^  Boston  Gynaecological  Journal,  vol.  ii,  p.  286. 

^  Dis.  of  Women.  Am.  ed.,  p.  110. 

«  Mai.  de  l'Ut6rus. 


INJECTIONS    INTO    THE    UTERINE    CAVITY,  269 

jtlilogistic  treatment,  the  effects  of  the  injection  being  exceedingly 
severe."  Noeggerath  reports  four  cases  treated  by  injections;  in 
the  first  case,  cure  was  happily  effected ;  in  the  second,  cure  was 
accomplished,  but  serious  and  protracted  symptoms  followed;  in 
the  third  case,  metro-peritonitis  was  set  up,  but  controlled ;  and  in 
the  fourth  case  the  patient  died. 

There  are  two  considerations  in  connection  with  this  sul)jeet 
which  must  not  be  lost  sight  of.  One  of  them  is  thus  stated  by 
Dr.  llenry  Bennet:  "this  accident,"  [fatal  peritonitis,  duo,  as  he 
thought,  to  passage  of  fluid  through  the  Fallopian  tubes]  "would 
})robably  have  occurred  nmch  oftener  than  it  has  done  in  the  hands 
of  French  [>ractitioners,  were  it  not  that  the  natural  coarctation  of 
the  OS  internum  must  have  generally  prevented  the  fluid  injected 
from  penetrating  into  the  uterine  cavity.''^  The  other  is  this,  that 
many  cases  of  peritonitis,  some  fatal  and  others  not  so,  which  have 
been  due  to  it  have  not  been  reported.  One  of  the  former  and  two 
of  the  latter  have  come  to  my  own  knowledge. 

The  explanation  formerly  given  of  the  accidents  which  may 
follow  this  procedure,  was  very  naturally  the  penetration  of  fluid 
through  the  Fallopian  tubes  into  the  peritoneum.  But,  although 
this  does  occasionally  occur,  (see  Von  Haselberg's  case  as  an  exam- 
ple,) it  has  been  proved  by  experiment  upon  the  dead  body,  as  well 
as  b}^  observation  of  the  practice  upon  the  living,  that  there  is  a 
resistance  on  the  part  of  the  tubes  which  ordinarily  prevents  it. 
Experiments  to.  test  this  matter  have  been  carefully  conducted  by 
Yidal,  Klemm,  and  Hennig,  and  all  with  the  same  result.  It  is 
probable  tliat  entrance  is  resisted  successfully  by  tubes  which  are 
healthy,  but  that  dilatation  and  atony  from  salpingitis  would  render 
the  patient  liable  to  the  accident. 

The  deduction  which  the  evidence  elicited  forces  upon  us  is 
self  evident,  namely,  that  at  the  same  time  that  this  method  of 
treatment  systematically  and  carefully  resorted  to  is  a  valuable 
resource  in  endometritis,  it  is  attended  by  many  and  great  dangers. 
While  it  is  proved  that  with  certain  precautions,  and  in  the 
hands  of  one  skilled  in  manipulations  of  this  character,  intra- 
uterine injections  may  usually  be  employed  with  safety  and  profit, 
it  is  equally  manifest  that  a  certain  number  of  deaths  have  been 
due  to  them,  and  that  they  are  frequently  followed  by  excessive 
pain  and  grave  constitutional  symptoms  when  the  essential  precau- 
tions are  neglected.  I  should  strongly  recommend  the  general 
practitioner  who  is  unfamiliar  with  the  treatment  of  uterine  dis- 


270  CHRONIC    CORPOREAL    ENDOMETRITIS. 


I 


orders  to  avoid  their  use  entirely,  except  in  cases  of  uncontrollable 
hemorrluio-e,  in  which  the  cervix  is  well  dilated  and  no  flexure  of 
the  uterus  exists.  When  he  is  induced  to  essay  this  plan  in  the 
treatment  of  corporeal  endometritis,  let  him  bear  in  mind  that  the 
possibility  of  easy  escape  of  the  fluid  injected  is  not  an  advantage 
merely,  but  an  essential  for  safety. 

One  very  recent  advocate  of  intra-uterine  injections  with  a  gre:;t 
deal  of  naivete  makes  the  following  statement -.^ 

"Thoiio-h  most  frequently  women  do  not  suffer  an^^  pain  when  injections, 
even  of  a  strong  sohition  of  caustic,  are  made  into  the  womb,  3'et  it 
sometimes  happens  that  symi)toms  which  give  great  alarm  to  inex- 
perienced persons  do  occur.  The  patient  suddenly  cries  out,  complains 
of  violent  colics,  of  pain  in  the  womb  like  that  of  labor;  the  abdomen 
liecomes  swollen,  the  face  becomes  pale,  the  extremities  cold,  the  pulse 
small,  and  the  patient  is  thrown  into  a  state  of  great  depression.  These 
symptoms  are  sometimes  accompanied  with  great  trembling  of  the  limbs 
and  vomiting, 

"  I  have  related  a  case  of  this  kind  at  the  end  of  this  memoir.  Such 
a  train  of  symptoms  is  undoubtedly  alarming  in  appearance,  but  is  not 
followed  by  any  fatal  result." 

I  confess  to  sharing  the  feelings  of  those  inexperienced  persons 
who  are  greatly  alarmed  at  the  development  of  "  such  a  train  of 
symptoms,"  for  that  it  is  alarming  not  only  in  appearance,  has  been 
more  than  abundantly  proved  by  the  occurrence  of  death  in  a 
number  of  cases. 

The  experiments  of  Yidal,  Hennig,  and  Klemm  force  us  to  admit 
that  passage  of  fluid  through  the  Fallopian  tubes  is  not  as  likely 
an  occurrence  from  intra-uterine  injections  as  one  would  suppose  it 
would  be  from  theoretical  reasoning.  Cohnhein,  to  whose  admir- 
able resume  of  this  subject  I  am  so  much  indebted,  appears  to  re- 
gard them  as  conclusive.  To  my  mind  they  are  very  far  from  being 
so.  It  is  important  to  note  that  experiments  performed  on  the 
cadaver  are  usually  applied  to  healthy  uteri  and  undilated  tubes, 
while  the  gynecologist  employs  these  injections  in  cases  where  the 
endometrial  mucous  membrane  is  inflamed,  and  the  Fallopian  tubes 
very  often  dilated  in  consequence.  Is  it  not  likely  that  a  disease 
which  overcomes  the  sphincteric  action  of  the  os  internum  uteri 
would  likewise  have  a  similar  eftect  upon  that  of  the  metro-salpin- 
gian  orifices  ?     Post-mortem  examination  proves  this  to  be  the  case. 

'  Gantillon  on  Uterine  Catarrh,  pamphlet,  1871. 


IJS'JECTIONS    INTO    THE    UTEEINE    CAVITY.  271 

Then  there  are  a  number  of  cases  on  record  in  which  such  imme- 
diate inflammatory  results  followed  in  the  peritoneum,  that  there 
can  be  little  doubt  as  to  the  occasional  relation  as  cause  and  effect. 
Take  for  example  the  report  of  a  case  by  Pedelaborde,  in  L 'Union 
Medieale  for  1850,  in  which,  "three  minutes  after  an  injection  of 
a  decoction  of  walnut  leaves,  severe  uterine  pains  ensued,  and  in  a 
few  hours  were  followed  by  acute  peritonitis."  A  similar  instance 
occurred  to  myself  from  injection  of  solution  of  persulphate  of 
iron.  Lastly,  in  a  fatal  case  occurring  to  Yon  Haselberg,  the  metal 
iron  was  detected  by  chemical  tests  in  one  tube.  If  in  a  uterus 
free  from  disease,  whether  in  tlie  cadaver  or  the  living  subject,  a 
syringe  be  carried  up  to,  but  not  through,  the  os  internum,  and  an 
injection  made,  the  fluid  will  not  enter  the  cavity  of  the  body^ — ■ 
and  why?  Because  corporeal  endometritis  has  not  destroyed  sphinc- 
teric  action  at  the  os  internum.  But  in  cases  of  endometritis, 
where  that  action  is  destroyed,  a  paralyzation  having  been  efl:ected 
there  by  disease,  how  different  is  the  case.  Under  such  circum- 
stances patients  are  often  unable  to  use  vaginal  injections,  for  the 
reason  that  the  fluid  at  once  passes  into  the  cavity  of  the  body,  and 
produces  violent  uterine  colics. 

These  cases  are,  I  claim,  precisely  parallel,  and  ignoring  the  fact 
upon  which  I  have  here  laid  so  much  stress  is  not  only  invalidating 
experiments  made  to  throw  light  on  a  point  of  clinical  importance; 
it  is  absolutely  perverting  them  to  the  production  of  evil. 

The  medicinal  substances  which  have  been  thus  employed  have 
varied  very  much  with  the  views  of  dift'erent  practitioners.  Vel- 
peau  employed  concentrated  solutions  of  nitrate  of  silver ;  Ricord 
from  tw^o  to  three  parts  of  tincture  of  iodine  to  one  hundred  parts 
of  water;  Evory  Kennedy  twenty  to  thirty  drops  of  nitrate  of  mer- 
cury; while  Sigmund  resorts  to  solutions  consisting  of  half  a 
drachm  of  nitrate  of  silver,  one  drachm  of  sulphate  of  copper,  one 
drachm  of  iodide  of  potassium  with  nine  grains  of  iodine,  two 
drachms  of  chloride  of  zinc,  or  three  drachms  of  perchloride  of 
iron,  to  three  ounces  of  water.  Hennig  employs  pure  warm  water 
for  a  time,  then  water  slightly  tinctured  with  iodine,  and  lastly, 
pure  tincture  of  iodine  or  solutions  of  silver;  Fiirst,  one  drachm 
of  nitrate  of  silver  to  two  of  water;  Martin,  of  Berlin,  five  grains 
of  aluminate  or  sulphate  of  copper  to  six  ounces  of  distilled  water; 
and  Kammerer  ten  to  twenty  drops  of  concentrated  solution  of 
chromic  acid;  Lugol's  solution  of  iodine  and  iodide  of  potassium, 
or  pyroligneous  acid,  in  weak  solution;  or  ten  grains  of  sulphate 
of  zinc  to  one  ounce  of  water. 


272  CHEONIC    COEPOREAL    ENDOMETRITIS. 

Before  leaving  this  subject  I  will  embody  in  a  series  of  proposi- 
tions the  most  important  facts  connected  with  it. 

1.  Intra-uterine  injections  may  produce  death  even  when  simple 
and  unirritating  fluids  are  employed,  by  peritonitis  due  to  absorp- 
tion of  the  fluid  and  subsequent  phlebitis ;  passage  of  fluid  into  the 
peritoneum ;  endometritis  (?) ;  or  by  sudden  entrance  of  air  into  a 
vein. 

2.  Even  when  no  such  dire  result  takes  place,  they  may  set  up 
severe  uterine  c(jlic,  with  tendency  to  collapse,  from  hysterical  neu- 
ralgia; violent  uterine  contractions  like  "after-pains;"  intense  irri- 
tation of  uterine  and  tubal  nmcous  membrane. 

3.  These  dangers  may  be  to  a  great  extent  avoided  by  attention 
to  certain  rules,  which  here  follow  : 

a.  Kever  inject  the  uterine  cavity  except  with  the  certainty  that 
the  injected  fluid  can  rapidly  escape.  Therefore  always,  unless  the 
OS  internum  be  very  much  dilated,  precede  the  injection  by  use  of 
a  tent,  and  always  use  a  syringe  insuring  immediate  reflux.  The 
method  for  employing  uterine  injections  is  very  simple,  but  should 
always  be  practised  with  great  system  and  caution.  A  single  tube 
of  silver  or  elastic  material  like  a  catheter,  with  eyes  at  the  side, 
may  be  used,  provided  the  little  syringe  which  projects  the  fluid  be 
immediately  removable  so  that  the  means  of  ingress  may  at  once 
become  the  means  of  egress.  AYe  may,  however,  still  more  certainly 
insure  egress  by  another  instrument.  The  necessity  for  return  of 
the  injected  fluid  is  so  great  that  canulte  with  double  canals  or  a 
canal  and  gutter  have  been  constructed  with  especial  reference  to 
this.  One  of  the  most  eftectual  and  safe  of  these  is  the  instrument 
shown  in  Fig.  77. 

Fig.  77. 


Molesworth's  double  canula  and  bulb  syringe  for  injecting  the  uterine  cavity. 

When  the  India-rubber  bulb  is  squeezed,  the  fluid  which  it  con- 
tains escapes  from  holes  in  the  end  of  the  canula,  and  at  once 
returns  through  another  tube  which  lies  alongside  of  it..  Then,  as 
the  compression  of  the  bulb  ceases,  a  vacuum  is  created,  which 
sucks  back  every  superfluous  drop. 

h.  The  best  substances  for  injection  are  tincture  of  iodine,  ni- 
trate of  silver,  sulphate  of  soda,  pyroligneous  acid,  carbolic  acid, 


INTRA-UTERINE    SCARIFICATION,  273 

and  sulphates  of  zinc,  copper,  or  iron  in  weak  solution.  It  is  best 
always  to  begin  with  the  use  of  weak  alkaline  injections  of  warm 
water,  not  only  to  see  how  tolerant  the  uterus  will  prove  to  the 
process,  but  because  in  the  experiments  of  Klenmi  on  the  cadaver, 
in  three  out  of  eighteen  oases,  blue  ink  injected  through  a  narrow 
OS  with  moderate  force  penetrated  the  venous  system  of  the  uterus 
and  broad  ligaments  without  apparent  laceration.  After  tolerance 
has  been  tested,  stronger  solutions  may  be  used. 

c.  Always  use  solutions  at  a  temperature  of  at  least  '^b'^  to  90°. 

d.  Wash  out  the  cavity  with  warm  fluid  before  using  the 
stronger  application;  and  in  injecting  always  be  sure  that  there  is 
no  air  in  the  syringe,  and  never  eject  the  fluid  which  it  contains 
with  force. 

e.  Never  employ  this  method  in  a  sharply  flexed  uterus  before 
replacement,  never  just  before  or  after  a  menstrual  period,  and 
never  when  pelvic  peritonitis  or  periuterine  cellulitis  has  recently 
existed. 

/.  After  the  use  of  this  plan  let  the  patient  lie  down  until  all 
sense  of  discomfort  has  passed,  and  confine  her  to  bed  and  give 
opium  freely  on  the  first  appearance  of  pain. 

4.  In  uterine  colic  the  most  certain  and  immediate  relief  will 
follow  the  use  of  morphia  by  the  hyjDodermic  syringe.  Astruc 
advised  the  addition  of  narcotics  to  injected  solutions  for  the  pre- 
vention of  the  accident. 

5.  Lastly,  although  this  plan  of  treatment,  robbed  of  many  of 
its  dangers  by  the  precautionary  measures  here  advised,  may  be 
comparatively  safe  in  the  hands  of  specialists  skilled  in  uterine 
manipulations,  it  will  always  remain  a  hazardous  method  for  the 
general  practitioner  who  lacks  such  skill  and  who  employs  instru- 
ments not  entirely  suited  to  the  purpose. 

The  Curette. — In  speaking  of  the  pathology  of  corporeal  endo- 
metritis, it  was  stated  that  the  diseased  membrane  in  time  develops 
upon  its  surface  fungoid  granulations,  mucous  cysts,  and  mucous 
polypi.  These  secondary  conditions  often  result  in  metrorrhagia  or 
menorrhagia.  Xot  only  does  the  gentle  application  of  the  little 
copper  curette  without  cutting-edge  accomplish  the  removal  of 
these,  it  produces,  when  thoroughly  ap[!lied,  an  altered  state  in  the 
entire  endometrial  membrane,  and  often  accomplishes  a  great  deal 
for  the  relief  of  the  disease.  In  cases  of  endometritis  engrafted 
upon  subinvolution  and  accompanied  by  hemorrhage,  it  is  espe- 
cially applicable. 
18 


274       AEEOLAR    HYPERPLASIA    OR    CHROXIC    METRITIS. 

Intm-uterine  Scarijimtion.^— This  consists  of  cutting  the  blood- 
vessels of  the  diseased  mucous  membrane  by  means  of  a  little 
knife  concealed  within  a  shaft  of  about  the  size  and  shape  of  a 
uterine  sound.  Being  carried,  sheathed,  into  the  cavity  of  the 
body  of  the  uterus,  the  blade  is  made  to  protrude  by  a  screw  in 
the  handle,  and  then  by  drawing  it  down  an  incision  is  made 
which  involves  the  mucous  and  submucous  tissues.  The  instru- 
ment of  Dr.  Pinkham,  of  Boston,  is  a  very  simple  and  effectual 
one  for  this  purpose.  I  have  little  experience  in  the  use  of  this 
means,  and  I  know  of  no  gynecologist  in  New  York  who  resorts 
to  it.  Dr.  Storer,  of  Boston,  its  originator,  tells  me  that  he  com- 
monly employs  it,  and  that  he  has  seen  the  best  results  follow  its 
use.  The  experience  of  the  gentlemen  above  mentioned  has  been 
sufficient  to  prove  that  the  method  is  free  from  danger,  and  that 
it  deserves  the  attention  and  confidence  of  gynecologists. 


CHAPTER    XVI. 

AREOLAR  HYPERPLASIA  OF  THE  UTERUS — THE  SO-CALLED  CHRONIC 
PARENCHYMATOUS  METRITIS. 

Definition  and  Nomevclature. — One  of  the  most  common  patho- 
logicul  combinations  which  confronts  the  gynecologist  is  that 
which  I  here  endeavor  in  as  concise  a  manner  as  possible  to 
picture.  A  patient  calls  upon  him  for  relief  of  backache  ;  jiclvic 
pains;  dragging  sensation  about  the  loins;  "bearing  down  pains;" 
leucorrhoea ;  menstrual  disorder,  tending  chiefly  to  excessive  flow ; 
throbbing  sensation  abont  the  uterus ;  general  feeling  of  despond- 
ency ;  malaise  and  weakness ;  and  irritability  about  the  bladder 
and  rectum.  All  these  rational  signs  pointing  to  the  uterus  as  the 
probably  delinquent  organ,  a  physical  exploration  is  made,  and 
furnishes  the  following  results :  the  uterus  is  usually  discovered 
to  be  in  the  condition  of  descent,  retroversion,  or  anteversion ;  it 
is  voluminous,  tender  to  the  touch,  and  evidently  engorged  with 

'  An  interesting  essay  upon  this  subject  may  be  found  in  "  The  Journal  of  the 

Gynecological  Society  of  Boston,"  vol.  i. 


AREOLAR    HYPERPLASIA    OR    CHRONIC    METRITIS.        275 

blootl ;  from  the  cervical  canal  a  leucorrlioeal  matter  pours ;  tlie 
probe  carried  to  the  fundus  finds  it  tender,  and  creates  the  liow  of 
a  little  blood;  the  cervix  is  often  in  a  condition  of  granular  or 
cystic  degeneration ;  and  a  low  grade  of  vaginitis  exists. 

To  this  pathological  combination  the  more  superficial  diagnosti- 
cian will  often  apply  a  name  which  announces  one  only  of  the  ex- 
isting conditions  ;  as,  for  example,  uterine  catarrh,  ulceration  of 
the  cervix,  or  retroversion  or  prolapse.  The  moi^'^  reflective  and 
intelligent  examiner  will  ordinarily  group  the  coincident  morbid 
states  together  under  the  name  of  "chronic  metritis.'"' 

The  latter  would  be  fully  sustained  in  his  position  by  authority 
as  abundant  as  it  is  orthodox,  for  by  systematic  waiters,  since  the 
days  of  Recamier,  tliis  uterine  state  has  been  described  as  one  of 
"  chronic  parenchymatous  metritis."  Onl}-  within  a  very  recent 
period  have  the  pathologists  of  the  German  school  begun  to  ques- 
tion the  validity  of  this  conclusion,  which,  taking  its  origin  in 
France,  was  spread  through  England  and  America  chiefly  by  the 
writings  of  Dr.  Henry  Bennet.  According  to  this  view  the  follow- 
ing pathological  changes  were  believed  to  be  those  resulting  in  the 
condition  just  described.  In  the  first  stage  the  parenchyma  was 
regarded  as  gorged  with  blood,  a  state  of  active  congestion  existing. 
This  was  supposed  soon  to  pass  into  the  second  stage,  consisting  in 
an  efiusion  of  lymph,  when,  unlike  a  similar  process  in  other  parts, 
the  morbid  action  ceased,  or  rather  did  not  advance,  and  unless 
relieved  by  treatment,  continued  stationary  for  a  length  of  time. 
The  third  stage  of  inflammation  in  other  parts,  that  of  suppuration, 
was  admitted  to  occur  rarely  here,  or  in  the  parenchyma  of  the 
body,  but  in  time  all  inflammatory  action  ceasing,  the  cervix 
remained  large  and  indurated  without  sensitiveness,  or  the  eft'used 
lymph  might  be  absorbed,  and  great  diminution  in  size  occur  with 
induration.  Were  this  really  the  case  the  condition  would  con- 
stitute one  of  inflammation,  even  if  we  restricted  ourselves  in  the 
use  of  that  ambiguous  term  to  the  narrow  and  precise  limits  pre- 
scribed by  Dr.  J.  Hughes  Bennett,  when  he  says,  "  It  should  be 
applied  only  to  that  j^erverted  alteration  of  the  vascular  tissues, 
which  produces  an  exudation  of  the  liquor  san«j!:uinis ;  it  is  this 
exudation  alone  which  can  be  held  to  unequivocally  characterize 
an  inflammation." 

Examined  more  recently,  however,  by  the  more  certain  and  less 
theoretical  processes  of  modern  science,  all  this  has  come  to  be 
looked  upon  as  erroneous.  Cases  which  were  formerly  regarded 
as  instances  of  inflammation  on  account  of  the  existence  of  enlarge- 


276       AREOLAR    HYPERPLASIA    OR    CHRONIC    METRITIS. 

merit,  congestion,  and  tenderness  upon  pressure,  the  microscope 
now  proves  to  have  been  instances  of  excessive  growth  of  the  con- 
nective tissue  of  the  uterus,  with  congestion,  and  resulting  hyper- 
sesthesia  of  its  nerves. 

It  may  result  from  three  entirely  different  pathological  states; 
first  from  interference  with  retrograde  metamorphosis  of  the  puer- 
peral uterus  from  any  cause;  second,  from  congestion  long  kept  up 
by  mechanical  causes,  such  as  displacement;  third,  from  a  forma- 
tive irritation  or  state  of  hypernutrition  excited  by  endometritis, 
or  the  existence  of  fibrous  tumors.  Whatever  be  the  originating 
pathological  condition,  tliat  wliieli  results  and  which  we  are  now 
considering  consists  in  hyperplasia  of  connective  tissue  as  its  most 
marked  feature,  and  of  congestion  and  nervous  hypersesthesia  as 
important  accompaniments. 

It  is  true  that  some  progressive  writers  still  cling  to  the  name 
chronic  inflammation,  and  apply  it  to  liypersemia  resulting  in 
hypergenesis  or  hypertrophy  of  connective  tissue,  but  this  is  by  no 
means  the  signification  which  is  ordinarily  given  to  the  term. 
Indeed,  with  reference  to  the  uterus,  so  vague  and  unsatisfactory  is 
the  appellation  chronic  metritis,  tliat  there  is  no  knowing  what 
idea  one  who  uses  it  really  intends  to  convey.  lie  who  has  in  the 
library  and  at  the  bedside  been  perplexed  and  disheartened  by  the 
constantly  recurring  uncertainty  which  it  lias  induced,  will  liave 
learned  to  appreciate  the  feeling  which  prompted  two  eminent 
pathologists,  Andral  and  J.  Hughes  Bennett,  to  propose  that  the 
vague  term  "inflammation"  should  be  expunged  from  our  nomen- 
clature.    To  quote  the  words  of  an  accomplished  writer  of  this  city: 

"The  entity  inflammation,  fallen  from  its  liigh  and  palmy  state, 
is  hanging  by  its  eyelids  as  a  pathogenic  factor  in  most  of  the 
organs  of  the  body ;  its  last  resting  place  seems  to  be  the  womb, 
and  here  still  it  has  a  good  foothold.  Why  should  uterine  patho- 
logy alone  be  cumbered  by  an  outAvorn  theory?" 

It  is  not  an  entirely  correct  statement  that  this  pathological 
doctrine  originated  in  France.  Upon  the  revival  of  gynecology 
in  that  country  by  the  labors  of  Recamier,  it  likewise  revived  and 
assumed  important  proportions.  But  the  theory  of  parenchymatous 
inflammation  as  explaining  this  condition  is  as  old  as  the  science 
of  medicine  itself,  and  it  certainly  is  a  peculiar  commentary  upon 
it,  that  now,  in  the  most  advanced  period  that  that  science  has  ever 
known,  the  retention  of  it  not  only  results  in  doubt,  uncertainty 
and  scepticism,  but  absolutely  creates  controversial  discussion, 
and  forms  sects  and  factions,  where  all  should  be  united  for  the 


AREOLAR    HYPERPLASIA    OR    CHROXIC    METRITIS.        277 

common  good.  "All  must  mourn,"  remarked  the  late  Professor 
Hodge,  "over  a  discrepancy  of  opinion  which  hears  so  directly 
on  the  treatment  of  such  painful  and  distressing  maladies."  "We 
cannot  hut  helieve,"  says  Meredith  Clymer,  "that  the  time  is  not 
far  oif  when  this  vexed  hut  important  question  will  he  re-opened, 
and  examined  in  a  fair-judging,  and  not  peremptory  and  dogmatic 
spirit,  uninfluenced  hy  prejudice,  prescription,  or  tradition;  and 
that,  measured  hy  a  new  standard,  and  settled  hy  the  requirements 
of  a  more  enlightened  knowledge  of  the  laws  of  life,  present  differ- 
ences will  he  reconciled,  hostile  opinions  conciliated,  and  the  angry 
voice  of  adverse  factions  he  heard  'not  any  more  forever.'  " 

Everywhere  throughout  the  recent  and  progressive  literature  of 
gynecology,  the  foreshadowing  of  the  advancing  change  in  views 
with  regard  to  this  suhject  will  be  recognized.  The  pendulum, 
swung  too  far  by  the  hand  of  Dr.  Henry  Bennet,  is  making  its 
inevitable  return.  That  it  may  stop  on  safe  middle  ground  must 
he  the  hope  of  all.  "The  determination  of  hlood  to  a  })art  here 
noticed,  characterized  hy  dilatation  of  the  arteries,  with  increased 
flow  of  blood  through  the  capillaries,  must  he  distinguished  from 
the  congestion  of  inflammation,  characterized  by  the  accumulation 
and  stagnation  of  red  and  white  corpuscles  in  the  vessels,  tending 
to  be  abnormally  adherent  to  each  other  and  to  the  vessels,"  says 
Dr.  H.  G.  Wright,*  quoting  from  Dr.  Aitken.  "Tested  by  this 
standard"  (that  of  Dr.  J.  Hughes  Bennett,  already  quoted),  says 
Dr.  Graily  Hewitt,^  "the  uterus  is  certainly  very  little  liable  to 
'  inflammation  ;'  exudation,  and  transformations  of  such  exudations, 
purulent  and  otherwise,  similar  to  what  may  be  witnessed  in  other 
organs  of  the  body,  being  very  rarely  witnessed  in  the  parenchyma 
of  the  uterus.  The  morbid  processes  with  which  we  are  familiar 
as  affecting  the  tissues  of  the  uterus  are  for  the  most  part  alterations 
of  growth,  irregularities  in  growth,  slight  modifications,  in  fact, 
of  the  processes  which  follow  each  other  in  due  succession  in  the 
natural  condition  of  things.  The  word  'inflammation,'  used  in 
Dr.  J.  Hughes  Bennett's  sense  of  the  word,  certainly  fails  to  convey 
an  adequate  idea  of  the  modifications  observed  under  such  circum- 
stances." "Diffuse  growth  of  connective  tissue,"  says  Klob,-''  "con- 
stitutes the  so-called  induration,  hitherto  considered  as  a  result  of 
parenchymatous  inflammation  of  the  uterus.  .  .  .  For  reasons 
mentioned,  I  would  also  advise  a  disuse  of  the  term  'chronic  in- 
flammation.' "      In  a  discussion*  upon  chronic  metritis  before  the 


'  Uterine  Disorders,  p.  218.  «  Dis.  of  Women,  p.  3(;3. 

3  Op.  cit.,  p.  129.  "  Med.  Eecord,  No.  92,  p.  475. 


278        AREOLAR    HYPERPLASIA    OR    CHRONIC    METRITIS. 

New  York  Academy  of  Medicine,  Dr.  Noeggeratli  limited  the  disease 
to  "growth  of  cellular  tissue  hoth  of  the  hody  and  neck,  occurring 
only  during  the  puerperal  state."  Dr.  Peaslee  preferred  "to  call  the 
disease  under  consideration  congestion,  rather  than  inflammation, 
because  it  has  none  of  the  events  of  inflammation ;"  and  Dr.  Kam- 
merer  expressed  the  view  that  "chronic  inflammation  of  the 
substance  of  the  non-puerperal  uterus  is  never  met  with  ;  what  has 
been  described  as  such  is  hypertrophy  of  connective  tissue,  resulting 
from  long  continued  hyperfemia." 

These  views,  which  among  men  who  are  in  the  advance  in  gyne- 
cology are  rapidly  gaining  ground,  are  not  sustained  by  analogical 
reasoning,  but  by  anatomical  proof.  I  know  of  nothing  which  will 
more  surely  convince  the  reader  of  the  necessity  for  an  alteration 
in  our  nomenclature  concerning  this  condition,  than  a  perusal  of 
Scanzoni's^  article  upon  it.  This  author,  after  heading  his  chapter 
"  Chronic  Parenchymatous  Inflammation  of  the  Womb,"  goes  on 
to  say :  "  The  nature  of  the  disease  would  then  be,  in  an  anatomical 
point  of  view,  an  hypertrophy  of  the  cellular  tissue."  Certainly 
the  "anatomical  point  of  view"  is  an  important  one,  and  it  is 
supported  by  what  we  observe  from  a  clinical  stand-point. 

So  much  evil  has  arisen  for  pathology  and  treatment  from  the  use 
of  the  term  chronic  metritis,  and  so  clear  a  demonstration  has  been 
made  that  the  condition  so  called  is  not  one  of  true  inflammation, 
that  some  other  appellation  is  not  only  desiral)le,  but  has  become 
absolutely  essential.  It  is  incontestable  that  there  is  a  peculiar 
condition  that  aftects  the  uterus  which  is  characterized  by  disten- 
tion of  bloodvessels  from  vital  or  mechanical  cause ;  eflusion  of  the 
serum  of  the  blood ;  and  hypergenesis  of  connective  tissue.  To 
denote  this  state,  gynecologists  have  long  required  a  name,  for 
medical  nomenclature  is  as  necessary  as  it  is  faulty.  Lisfranc  felt 
this  need  when  he  styled  it  "engorgement;"  Hodge  when  he  entitled 
it  "  irritable  uterus ;"  Bennet  when  he  called  it  "  metritis ;"  and 
others  also  have  acknowledged  the  necessity,  Klob,  for  example,  in 
"  habitual  hypersemia"  and  "  diftuse  proliferation  of  connective 
tissue,"  and  Kiwisch  in  "  infarctus." 

The  appellations  infarctus,  engorgement,  and  hypersemia  only 
convey  a  partial  idea  of  the  truth  ;  they  only  announce  one  element 
of  the  condition — congestion ;  while  that  of  irritable  uterus  ignores 
all  structural  change  in  announcing  another  element — nervous 
hypersesthesia.      At  the  same  time  that  the  phrase  "  difi'use  i.ro- 

'  Dis.  of  Females,  Am.  ed.,  p.  181. 


AEEOLAR    HYPERPLASIA    OR    CHRONIC    METRITIS.        279 

liferation  of  connective  tissue  due  to  bjpersemia,"  which  is  employed 
by  Klob,  clearly  defines  the  pathological  condition,  it  is  too  long 
and  burdensome  to  answer  the  purpose  of  a  name  to  be  conven- 
tionally employed.  If  there  be  a  term  now  in  existence  which 
does  really  convey  the  idea  truly  and  completely,  it  should  surely, 
in  the  interests  of  pathology  and  treatment,  as  well  as  out  of  con- 
sideration for  the  overburdened  student  of  medical  nomenclature, 
be  employed  in  preference  to  the  adoption  of  a  new  one.  Enlarge- 
ment of  an  organ  due  to  formation  of  new  cells  similar  to  those  of 
the  tissue  in  wdiicli  they  are  developed,  has  been  styled  by  Virchow, 
hyperplasia,  in  contradistinction  to  hypertrophy,  which  consists 
in  increase  of  size  from  distention  of  cells  already  existing.  As 
the  condition  of  the  uterus  now  under  consideration  is  one  arising 
from  over-excitation  of  the  vaso-motor  and  excito-nutritive  nerves, 
a  "formative  irritation,"  as  Klob  styles  it,  and  resulting  in  a 
numerical  hypertrophy,  it  appears  to  me  that  the  term  areolar 
hyperplasia  would  more  correctly  designate  it  than  any  other  with 
which  I  am  acquainted.  With  a  sincere  desire  to  lessen  and  not 
to  increase  the  labors  of  the  student  and  the  perplexities  of  the 
gynecologist,  I  shall  therefore  replace  the  confusing  term  chronic 
metritis,  by  that  of  areolar  hyperplasia  of  the  uterus. 

That  the  term  is  faultless,  I  do  not  claim.  To  one  unaccus- 
tomed to  it,  it  must  even  appear  peculiar.  I  have  merely  to  ask 
for  it  a  favorable  consideration  on  the  grounds  that  it  is  faithfully 
descriptive  of  the  condition  to  which  it  is  aj)plied,  and  that  a 
decided  necessity  for  some  such  term  exists. 

In  a  very  fair,  critical  review'  of  the  3d  edition  of  this  work, 
the  reviewer  remarks  that  this  name  "  involves  the  notion  that 
the  connective-tissue  elements  alone  hypertrophy,  and  disowns  the 
muscular  element  as  the  one  most  ^readily  provoked  to  increase. 
We  do  not  deny  that,  in  the  disease  in  question,  there  is  hyperplasia 
of  connective  tissue,  or,  at  any  rate,  of  non-muscular  elements  ;  but 
we  must  aver  our  belief  that  concomitantly  there  is  increase  in  the 
muscular  elements  also."  At  first  glance,  this  appears  to  be  a  very 
strong  point  of  objection;  but  I  think  that  even  the  writer  himself 
will,  upon  more  careful  examination  of  the  views  of  pathologists, 
agree  that  they  look  upon  the  proliferation  of  areolar  tissue  as 
always  the  characteristic  or  highly  predominant  feature  of  the  con- 
dition, and  regard  muscular  growth  as  an  insignificant  accompani- 
ment only.     For  obvious  reasons  it  is  impossible  for  me  to  quote 

'  Brit,  and  Foreign  Medico-Chirurgical  Rev.,  Jan.  1873. 


280       AEEOLAR    HYPERPLASIA    OR    CHRONIC    METRITIS. 

largely  to  sustain  this  position,  and  I  confine  myself  to  the  state- 
ment of  Professor  Klob/  who,  in  speaking  of  this  condition,  ex- 
presses himself  in  the  following  terms :  "  The  whole  uterine  con- 
nective tissue  sometimes  proliferates  either  without  accompanying 
increase  of  the  muscular  substance,  or,  if  this  does  occur,  the  con- 
nective tissue  predominates  to  such  an  extent  that  the  muscular 
substance  is  comparatively  of  not  much  account." 

It  is  true,  that,  while  most  who  have  investigated  this  subject 
have  fou'nd,  like  Klob  and  Scanzoni,  a  great  preponderance  of  con- 
nective tissue,  and  an  insignificant  increase  of  muscular  elements, 
some  have  declared  that  the  muscular  structure  is  greatly  hyper- 
trophied.  One  reason  for  this  variance  of  opinion  is  this:  the 
most  prolific  source  of  areolar  hyiierplasia,  the  so-called  chronic 
metritis,  is  interference  with  involution  of  the  parturient  uterus. 
What  begins  as  subinvolution  ends,  in  time,  in  a  condition  ordi- 
narily styled  chronic  metritis.  lie  who  examines  early  will  proba- 
bly find  a  greater  amount  of  muscular  elements  than  he  who  does  so 
later;  and  let  it  be  remembered  that  by  continental  writers,  with 
one  exception,^  no  recognition  is  made  of  subinvolution  as  a  disease 
distinct  from  what  Cliomel  styled  it,  post-puerperal  metritis.  In 
this  way  I  reconcile  the  researches  of  Klob,  whose  statement  I  have 
quoted,  with  those  of  Finn,*  who  reports  the  following  observations, 
made  at  the  Institute  of  Pathological  Anatomy  in  St.  Petersburg : 

"  1.  The  normal  disposition  of  tiie  single  muscular  fibre,  as  "well  as  of 
the  muscular  bundle,  remains  unchanged. 

"  2.  The  muscular  fibres  do  not  change  in  quality,  neitlier  is  their 
fatty  degeneration  a  pathognomonic  sign  of  this  disease. 

"  3.  The  muscular  fibres  are  always  extended  in  both  their  length  and 
breadth  above  iheir  normal  standard,  but  more  so  in  the  former 
direction.  , 

"  4.  The  number  of  fibres  is  always  largely  increased. 

"  5.  The  amount  of  connective  tissue  in  the  latter  stage  of  the  disease 
is  always  relatively  diminished,  but  absolutely  enlarged,  so  that  the  in- 
crease of  bulk  of  the  uterus  is  mainly  caused  by  the  liyperplasia  of  the 
muscular  fibres,  the  augmentation  of  the  connective  tissue  influencing  it 
but  little." 

If  the  disease  really  consists  in  a  proliferation  or  hypertrophy  of 
the  areolar  or  connective  tissue  of  the  uterus,  and  not  in  chronic 
inflammation,  it  would  certainly  be  advantageous  to  apply  to  it 


'  In  the  American  translation  of  Klob  the  rendering  is  not  tliis;  but  Dr.  Kani- 
merer  tells  me  that  that  passage  is  not  correct,  and  that  this  is. 

2  M.  Courly.  3  ^^  Journ.  Obstct.,  vol.  i,  p.  264. 


PATHOLOGY  OF  AREOLAR  HYPERPLASIA.       281 

r,ome  name  which  would  signify  that  fact.  "  Areolar  liyperplasia"* 
expresses  this  fact  concisely,  and  hence  I  liave  employed  it.  But 
the  only  proof  of  the  appropriateness  of  a  newly  applied  term,  is  its 
general  adoption.  If  this  be  accepted,  I  shall  feel  that  good  has 
resulted  from  my  effort;  if  its  approval  be  not  implied  by  adoption, 
I  shall  admit  with  regret  that  I  have  only  helped  to  render  confu- 
sion worse  confounded. 

Pathology  of  Areolar  Hyperplasia. — The  vast  majority  of  cases  are 
due  to  interference  with  that  retrograde  metamorphosis  occurring 
in  the  puerperal  uterus,  styled  involution.  To  comprehend  the 
pathology  of  cases  thus  arising,  it  will  be  necessary  to  consider  the 
physiology  of  that  process  as  well  as  the  pathological  conditions 
which  may  affect  it. 

It  is  only  within  the  last  quarter  of  a  century  that  we  have 
understood  the  process  by  which  the  uterus,  an  organ  measuring- 
three  inches,  in  the  short  space  of  nine  months  enlarges  so  as  to 
contain  a  child  or  even  two  or  three  children,  and  then  within  two 
months  after  delivery,  undergoes  so  rapid  an  absorption  as  to  return 
to  its  original  size.  The  credit  of  elucidating  the  subject  belongs 
chiefly  to  Germany,  for  it  is^to  Virchow,  Franz  Kilian,  Heschl, 
Kblliker,  and  Retzius  that  we  are  most  indebted. 

The  important  pathological  fact  that  arrest  in  a  disturbance  of 
this  process  constitutes  a  condition  of  disease  emanated  from  Sir 
James  Simpson,  who,  in  1852,  published  the  first  article  which 
drew  especial  attention  to  it.  His  article  was  entitled,  "Morbid 
Deficiency  and  Morbid  Excess  in  the  Involution  of  the  Uterus  after 
Deliver3\"  Since  that  time,  the  condition  which  now  engages  us 
has  become  generally  recognized  as  a  uterine  state  of  great  fre- 
quency and  moment. 

To  fully  comprehend  this  part  of  our  subject  it  is  necessary  to  bear 
in  mind  the  component  parts  of  the  healthy  uterine  parenchyma. 
It  consists  of  five  elements :  1st.  Fusiform  fibre  cells,  or,  as  they  are 
termed,  the  smooth  muscular  fibres ;  2d.  Round  and  oval  nuclei, 
which  are  supposed  to  be  elementary  fusiform  fibre  cells ;  3d. 
Amorphous  or  homogeneous  connective  tissue,  which  permeates  the 
parenchyma  and  binds  together  the  fibre  cells  and  nuclei ;  4th. 
Fibrillated  connective  tissue  or  white  fibrous  tissue ;  and  5th. 
Elastic  fibrous  tissue.  These  elements,  together  with  nerves,  blood- 
vessels, and  lymphatics,  make  up  the  tissue  of  the  uterus,  which  is 

'  Hypertrophy  signifies  excessive  growth  of  the  elements  of  a  tissue  already  exist- 
ing ;  hyperplasia  signifies  the  development  of  new  tissue. 


282       AREOLAR    HYPERPLASIA    OR    CHRONIC    METRITIS. 

covered  by  a  serous  membrane  externally  and  a  mucous  membrane 
within. 

Xo  sooner  does  this  structure  feel  the  stimulus  of  conception  than 
it  develops  rapidly,  partly  by  growth  of  already  existing  structures 
and  partly  by  new  formations.  The  round  or  oval  nuclei  rapidly 
develop  into  fusiform  cells,  and  these  as  rapidly  grow  into  colossal 
cells  which  grow  longer  and  more  powerful  as  pregnancy  advances. 
"  A  new  formation  of  muscular  fibre  also  takes  place,"'  the  con- 
nective tissue  elements  grow  proportionately,  and  the  bloodvessels 
enlarge. 

Parturition  occurs,  and  almost  immediately  a  retrograde  evolu- 
tion begins  to  restore  the  uterus  to  its  original  constituency.  The 
fully  developed  fibres  undergo  a  fatty  degeneration;  the  fat  thus 
formed  is  absorbed,  and  the  organ  rapidly  diminishes  in  size  and 
weight.  This  fatty  degeneration  aftects  the  organ  after  the  fourth 
day  subsequent  to  delivery,  and,  according  to  Heschl,  the  com- 
mencement of  a  new  formation  of  muscular  fibres  is  recognized  in 
the  fourth  week  after  labor,  in  the  form  of  nuclei  and  caudate  cells. 
At  the  end  of  the  eighth  week  the  uterus  has  returned  to  its 
normal  state. 

Certain  untoward  influences  may  retard  or  check  this  process,  and 
the  uterus  remain  flabby  and  large,  when  it  is  said  to  be  in  a  state 
of  subinvolution,  or  arrested  retrograde  evolution. 

Thus  far  we  have  been  dealing  witli  facts  thoroughly  ascertained 
by  histological  investigations  and  fully  established  by  evidence 
yielded  by  the  microscope.  But  from  this  point  the  pathology  of 
subinvolution  is  not  so  satisfactorily  settled.  Prof  Rimjison  de- 
clared that  the  disease  was  due  to  the  fact  that  "this  retrograde 
metamorphosis  of  the  uterus  has  not  taken  place  during  the  puer- 
peral month,  or  has  taken  place  only  to  such  an  imperfect  degree 
that  the  uterus  is  of  the  size  we  usually  see  it  have  at  the  end  of  the 
first  week  or  so  after  delivery,"  but  he  entered,  if  I  may  judge  from 
the  posthumous  volume  of  his  work  upon  Diseases  of  "Women, 
upon  no  detailed  account  of  the  existing  pathological  defect  in  the 
organ.  Since  his  writing,  it  appears  to  have  been  agreed  upon  that 
this  consists  of  persistence  of  the  muscular  fibres,  characterizing 
pregnancy,  in  a  state  of  fatty  degeneration.  Thus  Dr.  Wright^  says, 
"Pathologically  it  closely  corresponds  with  that  state  of  the  heart 
structure  so  admirably  described  by  Dr.  Richard  Quain,  and  com- 


'  Arthur  Farre,  Cyc.  Anat.  and  Phys.,  Article  Uterus. 
^  Uterine  Disorders,  p.  221. 


PATHOLOGY  OF  AREOLAR  HYPERPLASIA.       283 

monly  known  as  fatty  degeneration."  Dr.  West^  expresses  himself 
thus:  "thougli  fatty  degeneration  of  the  tissues  takes  place,  yet  the 
removal  of  the  useless  material  is  but  imperfectly  accomplished, 
while  the  elements  of  the  new  uterus  are  themselves,  as  soon  as 
produced,  subjected  to  the  same  alteration."  I  search  in  vain  the 
literature  of  the  pathology  of  this  subject  for  a  basis  for  these 
hypotheses.  That  literature  is  scanty  in  the  extreme  as  yet,  and 
the  subject  awaits  extended  researches  before  we  can  speak  intelli- 
gently of  it.  The  day  has  passed,  however,  when  we  can  let  proba- 
bilities in  pathology  pass  current  for  facts. 

The  best,  indeed  I  may  say  the  only  detailed  account  of  this 
condition  studied  by  the  microscope,  which  I  have  been  able  to 
obtain,  is  one  by  Dr.  Snow  Beck,^  of  London.  "  The  enlargement 
of  the  uterus  did  not  depend  so  much  upon  an  increase  in  the  size 
of  the  contractile  iibre-cells,  as  upon  an  increased  amount  of  round 
and  oval  globules,  with  amorphous  tissue  in  the  uterine  walls.  .  .  . 
The  essential  condition  of  the  organ  consisted  in  the  elements  of 
the  different  tissues  retaining  a  portion  of  the  natural  enlargement 
consequent  upon  impregnation.  But  this  enlargement  was  more 
due  to  the  increased  size  and  amount  of  the  soft  tissue  present  in 
the  walls  of  the  uterus,  as  well  as  at  the  internal  surface,  than  to 
the  increased  size  of  the  contractile  fibre-cells."  Marked  conges- 
tion existed,  the  bloodvessels  being  large  and  forming  a  complete 
and  continuous  system  with  the  capillary  network  on  the  inner 
surface  of  the  uterus,  l^o  allusion  to  preponderance  of  muscular 
fibres  is  anywhere  made,  and  no  mention  of  fatty  degeneration 
occurs. 

The  condition  of  the  uterine  cavity  is  important.  It  is  always 
enlarged,  the  glands  of  the  cervix  are  usually  enlarged,  and  upon 
the  lining  membrane  of  the  cavity  fungoid  growths  are  commonly 
developed. 

This  is  all  that  can  with  positiveness  be  said  of  the  pathology 
of  the  early  periods  of  subinvolution  in  the  present  undeveloped 
state  of  the  subject. 

The  uterus,  the  study  of  the  tissues  of  which  gave  Dr.  Beck's 
results,  measured  ^^  inches  in  length,  2|  inches  across  the  fundus, 
the  walls  were  If  inches  thick,  and  the  uterine  canal  was  3  inches 
deep. 

As  time  passes  the  uterine  walls  diminish  in  size,  their  tissue 

1  Dis.  of  Women,  3d  Eng.  ed.,  p.  89. 

2  London  Obstetrical  Trans.,  vol.  xiii,  p.  239. 


284       AREOLAR    HYPERPLASIA    OR    CHRONIC   METRITIS. 

^rows  less  vascular,  the  bloodvessels  become  smaller,  and  the  uterine 
cavity  assumes  smaller  dimensions.  But  the  organ  does  not  assume 
its  original  size ;  it  remains  large,  dense,  firm,  and  sensitive ;  for 
years  presenting  the  characteristic  appearances  of  the  so-called 
chronic  parenchymatous  metritis.  Although  taking  an  entirely 
difterent  view  of  the  pathology  of  chronic  metritis.  Dr.  West^ 
signalizes  almost  the  same  fact  in  the  following  words:  "It  must, 
however,  be  at  once  apparent,  that  after  inflammation  has  passed 
away,  its  effects  may  remain  in  the  larger  size  and  altered  structure 
of  the  womb,  and  that  the  very  nature  of  these  changes  Avill  be 
such  as  to  render  the  repair  of  the  damaged  organ  both  unlikely  to 
occur,  and  slow  to  be  accomplished,  and  must  leave  it  in  a  condition 
peculiarly  liable  to  be  aggravated  during  the  fluctuation  of  circu- 
lation, and  alterations  of  activity  and  repose,  to  which  the  female 
sexual  system  is  liable."  This  is  just  the  state  to  which  I  allude 
at  the  commencement  of  this  chapter,  as  one  existing  years  after 
labor,  and  which,  attended  by  congestion,  displacement,  catarrh, 
and  granular  degeneration,  is  styled  chronic  metritis.  It  is,  I  think, 
this  state  which  most  frequently  furnishes  instances  of  areolar  hy- 
perplasia to  the  microscope. 

Let  any  one  faithfully  and  patiently  watch  a  case  of  subinvolu- 
tion for  a  year  or  two  with  reference  to  this  point  as  I  have 
repeatedly  done,  and  I  cannot  doubt  that  he  will  have  the  same 
evidence  which  makes  me  so  strong  in  my  present  belief.  Lastly, 
let  it  be  remembered,  that  by  the  French  school  no  condition  of 
arrest  of  development  is  recognized  as  accounting  for  it ;  these  are 
cases  of  "  post-puerperal  metritis,"  metritis,  according  to  M.  Gal- 
lard,2  without  symptoms,  "  chronique  d'emblee." 

Does  any  one  claim  that  between  this  condition  and  chronic 
metritis  a  difterence  should  be  made?  Let  him  tell  me  by  what 
means  he  can  at  the  bedside  distinguish  one  from  the  other,  and  I 
may  agree  with  him.  There  are  no  means  for  such  difterentiation. 
If  the  uterus  be  very  large  and  the  patient  recently  delivered,  the 
case  is  termed  subinvolution  by  English  writers;  if  its  dimensions 
have  diminished,  years  have  elapsed  since  parturition,  and  the 
almost  universal  accompaniments  of  the  condition,  leucorrhoea, 
granular  degeneration,  and  displacement,  be  present,  it  is  styled 
chronic  metritis. 

Arrest  of  involution  of  the  puerperal  uterus  is  an  occurrence  of 
very  great  frequency.     It  constitutes  the  chief  cause  of  all  chronic 

'  Op.  cit.,  p.  89  2  Op.  cit..  p.  372. 


PATHOLOGY  OF  AREOLAR  HYPERPLASIA.       285 

uterine  disorders,  and  for  this  reason  its  importance  cannot  be 
overestimated.  Until  this  subject  receives  the  attention  which  it 
deserves,  the  present  confusion  as  to  the  causes,  pathology,  and 
general  features  of  chronic  metritis,  which  helps  to  weaken  uterine 
[lathologj,  must  continue. 

As  a  very  general  rule,  areolar  hyperplasia,  the  so-called  chronic 
metritis,  is  a  consequence  of  subinvolution.  This  constitutes  the 
(explanation  of  the  fact  that  so  large  a  number  of  women  with 
uterine  aftections  refer  their  illnesses  to  child-bearing,  and  that  so 
many  who  are  well  until  that  process  remain  invalids  afterwards. 
Go  back  to  the  commencement  of  all  cases  of  uterine  disease,  and  a 
very  large  proportion  will  date  from  parturition.  These  hyper- 
plastic or  subinvoluted  uteri  were  those  which  chiefly  furnished 
Lisfranc's  cases  of  "engorgement,"  which  Jobert  "melted  down'' 
with  the  actual  cautery,  and  which  hundreds  to-day  are  treating 
by  powerful  caustics  as  parenchymatous  metritis.  The  question 
may  be  asked,  do  I  myself  not  blister,  apply  leeches,  and  even 
amputate  the  cervix  in  these  cases?  The  element  which  sustains 
the  disease  is  an  excessive  supply  of  blood;  to  diminish  this  is  to 
strike  at  the  root  of  the  evil.  In  areolar  hyperplasia  I  blister 
lightly,  to  exert  an  alterative  influence  upon  the  nerves ;  for  the 
relief  of  coincident  congestion,  I  leech  occasionally,  as  I  would  for 
hyperemia  elsewhere;  and  I  amputate,  as  I  would  do  the  enlarged 
tonsils:  but  nowhere  would  I  treat  the  condition  as  inflammation. 

The  only  a})ology  which  I  ofl:er  for  enlarging  still  further  upon 
this  part  of  my  subject,  is  contained  in  the  fact  that  I  regard  it  as 
one  of  the  most  important  points  in  the  whole  of  uterine  pathology. 
Even  by  Parisian  writers,  who  above  all  others  have  been  wedded 
to  the  theory  of  chronic  inflammation,  the  dependence  of  a  peculiar 
form  of  so-called  chronic  metritis  upon  disordered  involution  has 
been  recognized.  "The  commencement  of  chronic  metritis,"  says 
Gallard,*  "  is  so  insidious,  that  it  is  often  difficult  to  determine  its 
date  in  each  particular  case.  So  rare  are  cases  of  true  acute  metritis 
which,  in  perpetuating  themselves,  become  chronic,  that  it  is 
generally  admitted  that  the  disease  is,  to  a  certain  extent,  chronic 
from  its  commencement.  Nevertheless,  I  consider  this  passing  of 
acute  into  chronic  metritis  as  much  more  frequent  than  most 
authors  think.  .  .  .  Aran,  after  having  contested  this,  was  forced 
to  recognize,  as  the  origin  of  the  greatest  number  of  cases  of  chronic 
metritis,  acute  metritis  following  parturition.      This  acute  stage 

'  LeQous  Cliniques  sur  les  Mai.  des  Feiniiies,  p.  372. 


286       AREOLAR    HYPERPLASIA    OR    CHRONIC    METRITIS. 

often  passes  unnoticed  among  the  sequela  of  labor,  scarcely  disturbed 
by  8lio;ht  febrile  movements  which  excite  no  suspicion  of  uterine 
inflammation  so  long  as  they  do  not  present  themselves  with  the 
alarming  symptoms  so  characteristic  of  puerperal  metritis.  Here 
we  see  arise  a  condition  which  Chomel  with  his  eminently  judicious 
and  practical  mind  was  obliged  to  distinguish  from  this  serious-^- 
disease   by  giving   it   a   particular   name,  that  of  post-puerperal 

metritis." "This  inflammation,  which  surprises  the 

uterus  before  it  has  finished  the  work  of  involution  which  would 
reduce  it  to  its  normal  size,  finds  in  the  histological  features  of 
this  organ  circumstances  most  favorable  as  well  for  its  development 
as  its  perpetuation  and  its  passage  into  the  chronic  stage." 

If  this  passage  be  read  with  the  key  which  I  here  offer,  it  be- 
comes plain  how  a  condition  arises  insidiously  after  labor  without 
the  symptoms  of  inflammation,  and  yet  ends  in  what  is  generally 
called  chronic  metritis ;  how  a  state  due  to  parturition  differs  so 
widely  from  ordinary  puerperal  metritis,  that  a  new  distinctive 
appellation  is  required  for  it;  how  metritis  appears  to  commence 
in  chronic  form  ;  how  Aran  found  this  latent,  undemonstrative, 
acute  disorder  the  "  source  of  the  majority  of  cases  of  chronic 
metritis ;"  and  how,  in  spite  of  the  obscurity  of  early  symptoms, 
M.  Gallard  is  forced  to  believe  that  the  chronic  disease  does  follow 
an  acute  puerperal  metritis,  the  development  of  which  is  obscured 
by  the  sequelae  of  labor.  The  supposed  acute  metritis,  without 
symptoms  to  announce  it,  which  is  conjured  up  to  sustain  an 
untenable  theory,  was  really  an  arrest  of  retrograde  metamorphosis ; 
the  chronic  metritis,  which  was  afterwards  found  to  exist  in  full 
development,  with  a  commencement  so  obscure  that  it  must  have 
been  "chronique  d'embl^e,"'  was  this  same  condition  passing  or 
having  passed  into  areolar  hyperplasia.  At  this  time  its  slowly 
retrograding  muscular  fibres  have,  to  a  great  extent,  passed  away, 
but  its  connective  tissue  continues  exuberant,  and  the  uterus 
remains  large,  swollen,  tender,  and  heavy. 

Compared  with  interference  with  involution,  all  other  pathologi- 
cal influences  become  comparatively  insignificant  as  causes  of  this 
condition;  nevertheless  they  must  receive  due  weight.  The  tissue 
of  the  virgin  uterus  presents  a  structure  unfavorable  to  this  disorder. 
That  of  a  uterus  once  affected  by  gestation  offers  a  more  propitious 
field  for  its  development. 

Displacement  of  the  uterus  at  first  results  in  passive  congestion, 

'  Gallaril,  op.  cit. 


PATHOLOGY  OF  AREOLAR  HYPERPLASIA.       287 

this  being  kept  up,  hypergenesis  of  connective  tissue  takes  place, 
ribroids,  whether  they  be  submucous,  subserous,  or  mural,  keep  up 
a  constant  nervous  irritation  that  induces  hyperemia,  which  proves 
the  tirst  step  towards  this  affection.  In  a  very  important  essay, 
Rouget^  proves  the  uterus  to  be  an  erectile  organ,  as  richly  supplied 
with  a  network  of  vessels  as  such  organs  always  are,  and  very  sub- 
ject to  active  physiological  congestion.  It  is  certain  that  such  a 
kind  of  hypersemia  attends  ovulation,  and  it  is  highly  probable 
that  sexual  congress  has  a  similar  result.  From  this  it  will  appear 
how  prolongation  of  the  molimen  menstruationis,  and  excessive  in- 
dulgence in  sexual  intercourse,  especially  near  menstrual  epochs, 
may  produce  evil  consequences.^ 

As  cardiac  diseases  and  abdominal  tumors,  which  interfere  with 
venous  return  through  the  vena  cava,  produce  blood  stasis  and 
oedema  of  the  feet,  of  the  labia  majora,  and  of  the  parts  about  the 
vagina,  so  do  they  result  in  the  same  way  in  the  uterus.  Klob 
declares  that  this  purely  passive  congestion  is  capable  of  inducing 
hypernutrition  and  hypertrophy  of  the  connective  tissue.^ 

It  has  been  already  said  that  in  acute  endometritis  the  hyper- 
femia  attending  the  disease  ordinarily  extends  to  the  parenchyma- 
tous layers  immediately  subjacent  to  the  diseased  mucous  mem- 
brane, and  that  in  chronic  endometritis  there  is  often  in  the  sub- 
mucous connective  tissue  an  absolute  hypertrophy.  In  some  cases 
the  process  passes  into  a  dift'use  proliferation  of  the  connective 
tissue  of  the  entire  uterine  wall.  Thus  as  a  result  of  cervical 
endometritis  we  sometimes  find  cervical  hyperplasia  resulting,  and 
so  with  the  disease  in  the  cavity  of  the  body.  As  I  have  already 
stated,  where  the  uterine  parenchyma  has  never  undergone  that 
physiological  'hypertrophy  and  retrograde  metamorphosis  attendant 
upon  utero-gestation,  endometritis  will  continue  for  a  long  period 
without  exciting  hyperplasia ;  but  where  such  changes  have  oc- 
curred, the  more  loose  and  permeable  texture  offers  itself  as  an 
easier  prey  to  the  morbid  process.  Thus  cervical  endometritis  will 
continue  for  years  in  a  virgin  without  any  apparent  enlargement 
of  the  structure  of  the  neck,  while  such  a  result  soon  follows  in 
a  woman  who  has  borne  children.  This  fact  has  not  attracted 
special  attention,  and  yet  it  is  a  point  which  every  practitioner 
must  recognize,  when  it  is  brought  to  his  attention,  as  one  which 

'  Rouget — Recherches  snr  les  Organes  erectiles  de  la  Fenime. 

2  Scanzoni  calls  attention  to  the  fact  that  it  is  met  with  ia  prostitutes. 

3  Klob,  op.  cit.,  p.  130. 


288       AREOLAE    HYPEP.PLASIA    OR    CHRONIC    METRITIS. 

is  familiar.  Under  these  circumstances  the  enlargement  is  not 
due  to  anything  absolutely  connected  with  parturition.  Parturi- 
tion has  been  the  predisposing  cause  ;  endometritis  the  exciting. 

A  very  striking  illustration  of  this  aftection  due  to  non-i)uerperal 
causes  is  related  by  Dr.  West,  whose  observation  seems  to  have 
led  him  to  very  similar  conclusions  with  mine.  "Some  years  ago," 
says  he,  "I  saw  a  lady,  aged  forty-three,  who,  during  thirteen  years 
of  married  life,  had  never  been  pregnant.  She  had  always  men- 
struated painfully,  and  rather  profusely ;  and  both  these  ailments 
had  by  degrees  grown  worse,  and  this  especially  during  the  last 
few  months.  She  complained  of  a  sense  of  weight  and  dragging 
immediately  on  making  any  attempt  to  walk,  and  induced  even  by 
remaining  long  in  the  sitting  posture.  .  .  .  Menstruation- was  very 
profuse,  accompanied  by  discharge  of  coagula,  while  at  uncertain 
inte'rvals  during  its  continuance  most  violent  paroxysms  of  uterine 
}:ain  came  on.  On  examination  the  enlarged  uterus  was  distinctly 
felt  above  the  symphysis  pubis,  as  large  as  the  doubled  fist,  and 
per  vaginam  the  whole  organ  was  found  much  enlarged,  and  much 
heavier  than  natural ;  the  cervix  large  and  thick,  but  not  indurated; 
the  OS  uteri  small  and  circular;  and  the  hymen  was  entire."  lie 
goes  on  to  say:  "Whenever  the  uterus  is  exposed  to  unusual  irri- 
tation, it  increases  in  size ;  not  necessarily,  nor  I  believe  generally, 
as  the  result  of  inflannuation,  but  because  the  organ  is  composed 
of  formative  material,  which  excitement  of  any  kind  will  call  into 
active  development." 

In  the  first  stage  of  the  disease,  the  hypertrophied  areolar  tissue 
is  congested,  containing  absolutely  more  blood  than  normal,  and 
the  whole  of  the  aifected  part,  neck,  body,  or  entire  uterus,  is 
greatly  increased  in  size  and  weight.  As  time  passes,  the  second 
stage  of  the  disorder  supervenes,  and  an  opposite  state  of  things 
is  set  up.  Klob  describes  it  in  these  words:  "The  parenchyma  on 
section  appears  white  or  of  a  whitish-red  color,  deficient  in  blood- 
vessels, from  compression  of  the  capillaries  by  the  contraction  of 
the  newly  formed  connective  tissue,  or  from  partial  destruction  or 
obliteration  of  vessels  during  the  growth  of  tissue;  the  firmness 
of  the  uterine  substance  is  also  increased,  simulating  the  hardness 
of  cartilage,  and  creaking  under  the  knife."  This  constitutes  a 
true  sclerosis'  of  the  uterus. 

Every  practitioner  must  have  met  with  cases  in  which  a  large. 


'  The  term  sclerosis  was,  I  believe,  first  applied  to  this  condition  by  Skene  of 

Brooklyn      Subsequently  Gallard  likewise  employed  it. 


COUESE    AND    TEllMIX  ATION.  289 

red,  engorged,  and  soft  uterus,  examined  after  an  interval  of  several 
years,  lias  been  found,  to  his  surprise,  to  have  become  small,  densely 
hard,  white,  and  ancemic,  and  its  cavity  diminished  in  size.  Such 
an  •  organ  removed  from  the  body  cuts  like  fibrous  tissue,  and 
appears  Avhen  cut  almost  as  dense  and  bloodless. 

In  leaving  this  important  and  interesting  part  of  my  subject,  let 
me  sum  up  what  has  been  said,  in  a  few  words: 

1st.  The  condition  ordinarily  styled  chronic  metritis  consists  in 
an  enlargement  of  the  uterus  due  to  hypergenesis  of  its  tissues, 
especially  of  its  connective  tissue,  which  induces  nervous  irrita- 
bility, and  is  accompanied  by  congestion. 

2d.  Decidedly  the  most  frequent  source  of  this  state  is  inter- 
ference with  involution  of  the  puerperal  uterus.  A  very  large 
proportion  of  the  cases  of  so  called  chronic  parenchymatous  metri- 
tis are  really  later  stages  of  subinvolution. 

3d.  Areolar  hyperplasia  is  often  induced  in  a  uterus  which  has 
once  undergone  the  development  of  pregnancy,  by  displacement, 
endometritis,  and  other  conditions  inducing  persistent  hypera2mia. 

4tli.  The  same  influences  may  possibly  produce  it  in  the  nullipa- 
rous  uterus,  (most  frequently  they  do  so  in  the  neck,)  but  such  a 
result  is  exceedingly  infrequent. 

5th.  However  produced,  the  condition  is  one  of  vice  of  nutrition 
engendering  hyperplasia  of  connective  tissue  as  its  most  striking 
feature,  and,  although  attended  by  many  of  the  signs  and  symptoms 
of  inflammation,  it  in  no  way  partakes  of  the  character  of  that 
process. 

It  has  been  maintained  by  some  that  acute  puerperal  metritis 
extends  itself  into  the  chronic  metritis  of  the  non-puerperal  state, 
and  this  form  of  the  afl:ection  has  been  diff'erentiated  from  sub- 
involution. I  have  seen  no  evidence  of  the  correctness  of  this 
view,  nor  do  I  believe  that  any  such  distinction  can  be  made  at 
the  bedside. 

Course  and  Termination. — The  length  of  time  which  this  condi- 
tion may  last  is  very  uncertain.  After  the  connective  tissue  once 
becomes  thoroughly  aft'ected  by  the  disease,  it  rarely  returns  to  its 
original  condition,  but  so  complete  is  the  relief  which  may  be 
aftbrded  the  patient  by  removal  of  those  concomitant  conditions 
that  attend  upon  it  and  increase  the  discomforts  which  are  due  to 
it,  that  she  will  often  for  years  imagine  herself  well.  Yer}'  sud- 
denh',  however,  imprudence  during  menstruation,  the  act  of  partu- 
rition, over-exertion,  or  some  other  influence  creating  congestion, 
will  produce  a  relapse  which  will  convince  her  of  her  error.  It  is 
19 


290       AREOLAR    HYPERPLASIA    OR    CHRONIC    METRITIS. 

astonishino;  to  what  an  extent  enlargement  of  the  cervix  as  a  result 
of  areolar  hyperplasia  will  go.  Sometimes  this  part  will  equal  in 
size  a  very  small  orange,  and,  tilling  the  vagina,  will  compress  the 
rectum  to  such  an  extent  as  to  interfere  with  its  functions.  Unin- 
terfered  with  by  art  the  disease  has  no  fixed  limits.  The  increase 
of  uterine  weight  which  it  induces  usually  results  in  displacement. 
This  increases  already  existing  congestion,  and  the  patient  suffers, 
until  the  menopause  at  least,  from  endometritis,  granular  cervix, 
and  the  ordinary  symptoms  of  displacement. 

In  some  cases  contraction  of  the  exuberant  tissue  occurs,  and 
uterine  atrophy  with  its  accompanying  symptoms  takes  place. 

Varieties. — Whatever  be  its  cause,  areolar  hyperplasia  may  affect 
the  entire  uterus ;  it  may  limit  itself  to  the  neck,  extending  from 
the  OS  externum  totheos  internum;  or  it  may  affect  the  body  from 
the  OS  internum  to  the  fundus.  The  habitat  of  hyperjilasia  limited 
to  the  cervix  is  represented  by  Fig.  78,  while  Fig.  79  represents 
that  of  the  corporeal  variety. 


Fi>.  78. 


Fi?.  79. 


The  dots  represent  the  site  of 
cervical  hyperplasia. 


The  dots  show  tlie  site  of 
corporeal  hyperplasia. 


Whether  arising  from  imperfect  involution  or  from  non-puer- 
peral causes,  this  limitation  to  cervix  or  body  will  be  frequently 
observed.  Dr.  West'  alludes  to  the  cervical  variety  as  "one  in 
which  the  enlargement  is  limited  to  the  neck  of  the  womb,  and 


Op.  cit.,  p.  93. 


FREQUENCY.  291 

sometimes  even  involves  only  one  lip,  generally  the  anterior.  In 
the  latter  case  it  is  usually  consequent  on  childbearing,  and  perhaps 
is,  strictly  speaking,  rather  the  result  of  a  partial  deficiency  of  in- 
volution of  the  uterus  than  the  effect  of  a  generic  hypertrophy  of 
the  part."  This  fact  was  first  announced  in  Great  Britain  by  Dr. 
Evory  Kennedy. 

Frequency. — This  affection  is  one  of  great  frequency,  and  as  it 
was  formerly  universally  regarded  as  chronic  parenchymatous  me- 
tritis, this  is  one  great  reason  why  inflammation  of  the  structure 
of  the  uterus  was  thought  to  be  so  common.  This  fact  makes  its 
careful  study  a  matter  of  great  moment  to  the  gynecologist.  I  do 
not  hesitate  to  declare  that  he  who  fully  masters  it  and  thoroughly 
appreciates  its  frequency  and  influence  will  possess  a  key  to  the 
management  of  numerous  cases  which  would  in  vain  be  sought  for 
elsewhere. 

As  I  have  before  remarked,  interference  with  that  retrograde 
metamorphosis  of  the  puerperal  uterus  which  is  now  styled  invo- 
lution is  in  the  great  majority  of  cases  its  cause.  Surprise  may  for 
this  reason  be  excited  by  the  assertion  that  of  all  forms  of  the 
affection,  the  cervical  variety  is  the  most  frequent.  The  reason  for 
this  is  to  be  found  in  the  facts  that  cervical  endometritis,  which  in 
multiparous  women  proves  a  not  infrequent  source  of  the  disorder, 
is  more  common  than  the  kindred  affection  of  the  body  ;  tliat  the 
cervix  is  peculiarly  exposed  to  mechanical  injury  from  coition, 
friction  against  the  vaginal  walls,  and  laceration,  occurring  during 
parturient  distention;  that  after  childbearing  the  connective  tissue 
at  this  point  is  looser  and  more  permeable  than  that  of  the  body ; 
and  that  when  involution  is  retarded  for  some  montlis  and  then 
is  accomplished,  it  sometimes  takes  place  in  the  body,  but  fails  to 
do  so  in  the  neck  from  that  exposure  to  injurious  influences  which 
has  just  been  alluded  to. 

The  body  of  the  uterus  is  so  completely  removed  from  contact 
with  mechanical  agencies  outside  of  the  abdomen  that  this  part  of 
the  organ,  as  already  stated,  is  not  so  frequently  affected  by  hyper- 
plasia as  the  corresponding  tissue  of  the  cervix.  Still  it  is  by  no 
means  unfrequently  diseased.  A  large  number  of  cases  of  obstinate 
uterine  disorders  occurring  as  a  remote  result  of  parturition  are 
really  of  this  nature,  and  the  displacements,  rebellious  leucorrhcea, 
and  other  concomitant  evils  which  characterize  them,  are  merely 
symptoms  of  this  affection  or  of  some  of  its  resulting  complica- 
tions. An  important  fact  connected  with  this  state  is  that  where 
hypertrophy  of  the  connective  tissue  exists,  transient  attacks  of 


292       AREOLAR    HYPERPLASIA    OR    CHRONIC    METRITIS. 

active  concrestion  frer[ueiitlj  occur  and  excite  acute  symptoms. 
These  pass  awaj,  leaving  the  basis  of  the  aifection  in  its  original 
state,  again  to  return  with  all  the  signs  of  relapse.  And  thus  a 
series  of  short  but  severe  exacerbations  go  on  developing  them- 
selves in  the  ordinary  course  of  an  attack  of  the  disorder. 
Predisposing  Causes. — Tliese  may  be  enumerated  as — 

A  depreciation  of  the  vital  forces  from  any  cause ; 
Constitutional  tendency  to  tubercle,  scrofula,  or  spansemia ; 
Parturition,  especially  when  repeated  often  and  with  short  in- 
tervals ; 

Prolonged  nervous  depression ; 

A  torpid  condition  of  the  intestines  and  liver. 

S^ulliparity  secures,  to  a  very  great  extent,  an  immunity  from 
the  disease,  and  multiparity  constitutes  a  most  important  predis- 
posing cause.  This  fact  arises  not  merely  from  its  being,  as  it  often 
is,  an  immediate  consequence  of  the  parturient  act,  but  from  the 
peculiar  tissue  changes  of  utero-gestation  rendering  the  uterus 
prone  to  its  development.  "  Frequently,"  says  Klob,  "  this  prolifera- 
tion of  connective  tissue  is  developed  after  rejjeated  deliveries  in 
rapid  succession  without  any  previous  or  existing  inflammation, 
....  and  sometimes  is  developed  in  consequence  of  the  puerjjeral 
condition."  Its  "causes  must  be  sought  for  in  habitual  hyperaemia ;" 
consequently  whatever  state  gives  a  tendency  to  this  must  be  re- 
garded as  a  predisposing  cause,  while  one  which  induces  and  per- 
petuates it  must  be  looked  upon  as  exciting.  Tlie  woman  who  has 
never  been  pregnant  is  much  less  liable  to  areolar  hypeq>lasia  than 
she  whose  uterus  has  undergone  the  tissue  changes  of  utero-gesta- 
tion. Xevertheless,  in  very  rare  and  exceptional  cases,  I  think 
that  she  may  suffer  from  it.  In  the  whole  of  my  experience  I 
have  seen  but  two  or  three  cases,  and  the  diagnosis  in  these  is  based 
ujx>n  clinical  evidence  alone. 

Here  let  me  guard  the  reader  against  a  fallacious  argument  which 
is  often  used  in  reference  to  this  matter.  As  areolar  hyperplasia  is 
rarely  seen  except  in  women  who  have  borne  children,  it  is  said 
that  it  is  always  the  result  of  interference  with  involution.  TTiis 
is  incorrect.  A  woman  bears  a  child,  has  no  post-partum  trouble, 
and  goes  through  uterine  involution  perfectly.  A  year  or  two 
afterwards  she  has  endometritis.  This  in  time  produces  areolar 
h  vperplasia  with  its  usual  sjTnptorns  and  physical  signs.  The  same 
kind  and  degree  of  endometritis  in  a  nulliparous  woman  would 
have  lasted  for  years  without  parenchymatous  complication.     In 


S  Y  M  P  T  O  M  S .  293 

tlie  former  case  the  endoriietric  disease  existed  on  ground  favorable 
to  liyperplasia,  because  an  important  predisposing  cause  existed.    In 
the  latter  such  predisposition  was  wanting. 
The  exciting  causes  are  the  following: 

Over-exertion  after  delivery; 

Puerperal  pelvic  intiammation ; 

Laceration  of  the  cervix  uteri ; 

Displacements ; 

Endometritis ; 

Neoplasms; 

Cardiac  disease; 

Abdominal  tumors  pressing  on  the  vena  cava; 

Excessive  sexual  intercourse. 

After  delivery  many  of  both  these  sets  of  causes  are  developed 
by  the  pernicious  system  of  management  which  nurses  frequently 
adopt.  The  nerve  and  blood  states  of  the  woman  are  depreciated 
by  starvation,  impure  air,  and  disturbance  of  sleep  by  attention  to 
the  wants  of  the  child,  while  the  enlarged  uterus  is  forced  into 
retroversion  and  the  congestion  which  it  induces,  by  a  very  tight 
bandage,  rendered  still  more  hurtful  by  a  thick  compress  over  the 
uterus.  The  practitioner  who  regards  delivery  of  the  placenta  as 
the  end  of  the  third  stage  of  labor  furnishes  a  marked  f)redisposing 
cause.  The  third  stage  of  lal)or  consists  in  complete  and  perma^ 
nent  contraction  of  the  uterus,  and  may  not  be  accomplished  for 
hours  after  the  expulsion  of  the  placenta.  No  obstetrician  has 
done  his  duty  who  leaves  his  patient  before  its  accomplishment. 

Symptoms. — It  is  impossible  to  present  the  symptoms  of  this  con- 
dition entirely  separated  from  those  of  complications  which  verj- 
commonly  attend  it,  such,  for  example,  as  displacement,  laceration 
of  the  cervix,  ovarian  congestion,  granular  cervix,  etc.  These 
states  of  course  produce  symptoms  of  their  own  which  mingle  witli 
those  of  the  main  disorder.  The  symptoms  then,  which  are  due  to 
areolar  hyperplasia  and  its  almost  inevitable  complications,  are  the 
following.     If  the  cervix  alone  be  affected  there  are: 

Pain  in  back  and  loins; 
Pressure  on  bladder  or  rectum ; 
Disordered  menstruation ; 
DiiSculty  of  locomotion ; 
Nervous  disorder; 
Pain  on  sexual  intercourse; 


294       AREOLAR    HYPERPLASIA    OR    CHRONIC    METRITIS. 

Dyspepsia,  headache,  and  languor ; 
Leucorrhcea. 

If  tlie  aifection  be  general  or  corporeal,  graver  symptoms  mani- 
fest themselves.'     Chief  among  these  are: 

A  dull,  heavy,  dragging  pain  through  the  pelvis,  much  increased 
by  locomotion; 

Pain  on  defecation  and  coition; 

Dull  pain  beginning  several  days  before  menstruation,  and  last- 
ing during  that  process ; 

Pain  in  the  mammae,  before  and  during  menstruation ; 

Darkening  of  the  areolae  of  the  breasts; 

Nausea  and  vomiting ; 

Great  nervous  disturbance; 

Pressure  on  the  rectum  with  tenesmus  and  hemorrhoids; 

Pressure  on  the  bladder  vrith  vesical  tenesmus; 

Sterility. 

Physical  Signs  of  Cervical  Hyperplasia. — Vaginal  touch  will  gene- 
rally discover  that  the  uterus  has  descended  in  the  pelvis  so  that 
the  cervix  will  rest  upon  its  floor.  The  cervix  will  be  found  to  be 
large,  swollen,  and  painful,  and  the  os  may  admit  the  tip  of  the 
finger.  If  the  finger  be  j^laced  under  the  cervix  and  it  be  lifted 
up,  pain  will  usually  be  complained  of,  and  if  it  be  introduced  into 
the  rectum  so  as  to  press  upon  the  cervix  as  high  as  the  os  inter- 
num, it  will  often  reveal  a  great  degree  of  sensitiveness.  Under 
these  circumstances  the  direction  of  tlie  uterine  axis  will  generally 
be  found  to  be  abnormal.  The  cervix  will  in  some  cases  have 
moved  forwards  and  the  body  backwards,  or  the  opposite  change 
of  place  may  have  occurred. 

Physical  Signs  of  Corporeal  Hyperplasia. — If  two  fingers  be  carried 
into  the  vagina  and  placed  in  front  of  the  cervix  so  as  to  lift  the 
bladder  and  press  against  the  uterus,  while  the  tips  of  the  fingers 
of  the  other  hand  be  made  to  depress  the  abdominal  walls,  the 
body  of  the  uterus  will,  unless  the  woman  be  very  fat,  be  distinctly 
felt,  should  the  organ  be  anteflexed.  Should  it  not  be  detected,  let 
the  two  fingers  in  the  vagina  be  now  carried  behind  the  cervix  into 
the  fornix  vaginae,  and  the  effort  repeated ;  if  the  uterus  be  retro- 
flexed  or  retroverted,  or  even  in  its  normal  place,  it  will  be  detected 
at  once.     By  these  means  we  may  not  only  learn  the  size  and  shape 

'  It  must  not  be  supposed  that  all  these  symptoms  occur  in  all  or  even  in  the 
majority  of  cases.  In  many  cases  few,  and  in  some  almost  none  of  them  will  be 
recognized. 


DIFFEKENTIATION.  295 

of  the  organ,  but  its  degree  of  sensitiveness.  This  may  likewise  be 
accomplislied  to  a  certain  extent  by  rectal  touch.  The  uterine 
probe  may  then  be  introduced,  the  cavity  measured,  and  the  sensi- 
tiveness of  the  walls  carefully  ascertained. 

A  point  which  should  be  settled  before  the  diagnosis  can  be  con- 
sidered complete,  will  be  whether  the  cervix  alone  is  affected,  or 
whether  its  enlargement  is  only  a  part  of  a  general  uterine  develop- 
ment. To  determine  this  question,  two  means  are  at  command: 
first,  the  examiner,  introducing  one  or  two  fingers  under  the  body 
of  the  uterus,  and  depressing  the  abdominal  walls  by  the  other 
hand,  so  as  to  clasp  the  fundus,  ascertains  whether  it  is  larger  than 
it  should  be,  or  of  normal  size  and  free  from  sensitiveness.  He 
then  passes  the  uterine  probe  into  the  cavity  of  the  body,  and 
measures  it.  If  the  uterine  cavity  be  increased  in  size,  the  evidence 
is  in  favor  of  the  disease  having  extended  to  the  tissue  of  the  body. 
Should  its  size  be  normal,  this  is  probably  not  the  case.  This  sign 
is  not,  however,  to  be  entirely  relied  upon. 

JDifferentiaiion. — AVhen  the  whole  uterus  is  affected,  or  the  body 
of  the  organ  alone  is  enlarged,  the  diseases  with  which  areolar 
hyperplasia  may  be  confounded  in  its  first  stage,  are: 

Pregnancy ; 

Neoplasms ; 

Periuterine  inflammations. 

From  these  a  careful  differentiation  should  be  made ;  for  if  m 
error,  the  practitioner  would  not  only  fail  in  giving  relief,  but,  in 
some  cases,  might  do  great  injury.  For  example,  an  examination 
by  the  probe  might  produce  abortion,  or  so  aggravate  periuterine 
inflammation,  as  to  cause  serious  and  alarming  consequences.  The 
introduction  of  the  probe  or  sound  should,  for  this  reason,  be  prac- 
tised with  great  caution,  and  only  when  good  reason  exists  for 
supposing  pregnancy  and  periuterine  inflammation  absent. 

Between  pregnancy  and  endometritis  with  corporeal  hyperplasia, 
there  is  a  chance  of  error  in  diagnosis ;  for  in  both  there  are  en- 
largement of  the  breasts,  darkening  of  the  areolae,  enlargement  of 
the  uterus,  derangement  of  the  nervous  system,  and  nausea  and 
vomiting.  In  the  one,  however,  menstruation  does  not  cease,  there 
is  no  kiesteine  in  the  urine,  there  is  great  sensitiveness  of  the  body 
of  the  uterus,  and  an  abundant  leucorrhoea.  Dr.  Tilt  has  drawn 
especial  attention  to  this  important  fjict,  in  connection  with  endo- 
metritis: "When  most  of  the  symptoms  of  early  pregnancy  are 
present,"  says  he,  "without  menstruation  being  suspended,  in  com- 
paratively young  women,  internal  metritis  may  be  suspected. '" 


296       AREOLAR    HYPERPLASIA    OR    CHRONIC    METRITIS. 

Fibrous  growths  in  the  uterine  walls  will  sometimes,  from  the 
peculiar  symmetry  of  their  development,  completely  mislead  us, 
giving  uterine  enlargement,  leucorrhoea  of  bloody  character,  etc. 
I  have  now  in  my  possession  a  uterus  in  the  anterior  wall  of  which 
a  fibrous  tumor,  equal  in  size  to  a  goose's  egg,  gives  upon  super- 
ficial examination  all  the  appearances  of  engorgement  and  hyper- 
trophy of  uterine  tissue  with  anteflexion  and  endometritis.  In  the 
same  manner  polypoid  growths  or  submucous  fibroids  might  give 
trouble  in  diagnosis.  Under  such  circumstances  reliance  would 
have  to  be  placed  upon  the  use  of  the  sound,  conjoined  manipula- 
tion, and  tents,  together  with  the  rational  signs. 

Periuterine  inflammations  fix  the  uterus,  create  hardness  and 
swellings  in  the  iliac  fossae  and  pouch  of  Douglas,  and  sometimes 
produce  purulent  discharges. 

Sometimes,  suspicion  of  scirrhous  cancer  in  an  early  period  being 
entertained,  it  becomes  necessary  to  decide  between  its  existence 
and  that  of  the  second  stage  of  areolar  hyperplasia  or  sclerosis. 
Scanzoni  doubts  the  possibility  of  deciding,  but  it  appears  to  me 
that  the  investigator  will  usually  succeed  in  doing  so,  by  the  fol- 
lowing comparison  of  signs  and  symptoms: 

In  Cervical  Sclerosis.  In  Scirrhoiis  Cancer. 

The  patient  shows  no  cachexia.  She  often  does. 

There  is  tendency  to  amenorrhoea.  There  is  tendency  to  hemorrhage. 

The  history  usually  points  to  parturition.  It  does  not. 
It  has  been  preceded  by  symptoms  of  uterine     It  has  not. 

enlargement. 

The  cervix  feels  like  dense  fibrous  tissue.  It  feels  almost  like  cartilage. 

The  body  is  perhaps  implicated.  It  is  very  rarely  so. 

A  sponge-tent  softens  the  tissue.'  It  leaves  it  hard  and  dense. 

Prognosis. — The  prognosis  in  hyperplasia  of  the  entire  uterus  or 
of  the  body  alone  is  unfavorable  with  regard  to  complete  cure, 
though  highly  favorable  with  reference  to  great  relief  of  symp- 
toms and  to  danger  to  life.  Should  the  patient  be  approaching  the 
menopause,  it  is  possible  that,  after  the  functions  of  the  uterus 
cease,  atrophy  may  occur  and  relief  be  obtained.  But  one  cannot 
be  sure  even  of  this,  for  the  monthly  discharge  may  give  place  to 
metrorrhagia,  or  all  the  symptoms  may  continue  in  spite  of  the 
menstrual  cessation.  Under  a  course  of  local  treatment,  combined 
with  one  conducted  with  special  reference  to  tlie  general  sj'stem, 
hope  may  always  be  held  out  that,  although  restoration  of  the 
uterus  to  its  normal  condition  may  not  be  effected,  the  evils  result- 


'lliis  test  originated  with  Spiegelberg. 


TREATMENT.  297 

ing  from  the  comi^lications  of  this  disease  can  be  so  fully  controlled 
that  comfort  will  be  obtained.  When  the  neck  of  the  uterus  alone 
is  affected,  a  favorable  prognosis  may  always  be  made,  for  here 
there  are  fewer  grave  complications  to  be  encountered  ;  such,  for 
example,  as  corporeal  endometritis,  menorrhagia,  etc.  The  dis- 
eased part  is  likewise  more  accessible  to  local  treatment,  and  is 
also  a  much  less  sensitive  and  important  part  of  the  organism  ;  1 
might  indeed  almost  say  a  less  important  organ,  so  distinct  are  the 
uterine  body  and  neck  physiologically  and  pathologically.  As  I 
have  elsewhere  stated,  the  prognosis  will  depend  in  a  great  degree 
upon  the  patient.  If  she  be  unwilling  to  sacrifice  her  inclinations 
and  pleasures,  but  half  fulfil,  the  directions  of  the  attending  phy- 
sician, and  clandestinely  expose  herself  to  prejudicial  influences, 
the  treatment  will  accomplish  nothing.  In  the  case  of  a  reason- 
able patient,  who  appreciates  what  is  at  stake,  and  is  anxious  to 
regain  her  health,  it  may  be  regarded  as  favorable. 

Complications. — Areolar  hyperplasia  may  give  rise  to  many  and 
serious  complications,  as,  for  example,  displacements,  cystitis,  rec- 
titis,  cellulitis,  endometritis,  menstrual  disorders,  hysteria,  dys- 
pepsia, ovarian  disorders,  etc. 

The  question  has  recently  been  raised  by  Dr.  Noeggerath  as  to 
the  causative  influence  of  this  disease  in  the  production  of  can- 
croid aftections.  In  an  essay  read  before  the  New  York  Academy 
of  Medicine  in  1869,  he  reported  six  cases  which  he  regarded  as 
due  to  the  "  transformation  of  the  tissue  aft'ected  with  chronic 
metritis  into  epithelioma  or  cauliflower  excrescence."  The  object 
of  the  essay  was  "  to  prove  that  the  tissue  of  the  uterus  affected 
with  chronic  metritis  is  apt  to  be  transformed  into  i)apillary  epi- 
thelioma." My  experience  has  never  furnished  me  with  a  case 
illustrative  of  the  correctness  of  Dr.  Noeggerath's  opinion.  It 
certainly  cannot  be  an  ordinary  sequence  of  events,  for  the  sub- 
ject long  ago  attracted  attention,  and  I  know  of  no  recent  author 
who  takes  similar  ground.  Klob's^  opinion  is  expressed  in  these 
words :  "  What  has  been  said  by  various  authors  on  the  relations 
of  diftuse  growth  of  connective  tissue  to  the  development  of  carci- 
noma must  be  considered  as  a  mere  hypothesis." 

Tiratment. — Let  me  urge  upon  the  practitioner,  as  a  rule  to  be 
observed  in  every  case,  before  treatment  is  adopted  for  this  dis- 

'  It  must  be  noted  that  Klob  alludes  to  carcinoma,  while  Noeggerath  limits  his 
statement  to  epithelioma. 


298        AKEOLAR    HYPERPLASIA    OE    CHRONIC    METRITIS. 

order,  to  examine  for  and  remove,  if  discovered,  the  five  following 
complications  which  very  often  accompany  areolar  hyperplasia, 
and  establish  symptoms  which  greatly  increase  the  evils  attending 
it.  So  important  do  I  consider  them,  that  I  give  them  decided 
prominence. 

1st.  Laceration  of  the  cervix  uteri  which  creates  intense  nervous 
irritation,  both  immediate  and  reflex,  and  consequent  uterine  con- 
gestion and  neuralgia. 

2d.  Displacement  of  the  uterus,  which  results  in  vascular  engorge- 
ment, dragging  upon  uterine  ligaments,  mechanical  interference 
with  surrounding  parts,  and  difiiculty  in  locomotion. 

3d.  Fungoid  degeneration  of  the  endometrium  which  results  in 
profuse  leucorrhoeal  and  bloody  discharges. 

4th.  Granular  and  cystic  degeneration  of  the  cervix  which  pro- 
duce nervous  and  vascular  derangement  of  the  uterus,  leucorrhoea, 
and  menorrhagia. 

5th.  Vaginitis  which  is  excited  by  the  discharge  dependent  upon 
engorgement  of  the  endometrium. 

He  will  be  most  successful  in  the  treatment  of  areolar  hyperplasia 
who  most  assiduously  searches  for  and  cures  these  complicating 
conditions  before  addressing  remedies  to  the  main  aflection. 

Laceration  of  the  cervix,  and  exposure  of  the  delicate  walls  of 
the  cervical  canal  to  friction  against  the  vagina,  is  so  frequently 
not  only  a  concomitant  circumstance  but,  I  think,  a  cause  of  this 
condition,  by  interfering  with  involution,  that  it  should  always  be 
looked  for.  Let  it  not  be  supposed  that  a  mere  visual  inspection 
will  reveal  its  existence.  It  will  often  fail  to  do  so  while  the 
red  and  excoriated  cervical  walls  are  being  for  long  periods 
treated  for  so-called  ulceration  by  caustics  and  alteratives.  To  test 
the  question,  a  tenaculum  should  be  fixed  in  each  labium  cervicis, 
and  these  should  be  approximated  so  as  to  present  to  the  eyes  of 
the  examiner  the  perfect  cervix  as  it  existed  before  the  accident. 
Once  discovered,  the  inner  surfaces  of  the  torn  lips  should  be 
thoroughly  pared  and  brought  together  by  suture.  Such  an  opera- 
tion will  often  have  a  most  happy  effect  upon  the  uterine  disorder; 
nervous  irritability  will  disappear,  and  nutrition  become  greatly 
improved  by  removal  of  this  focus  of  irritation. 

If  displacement  exist,  great  benefit  will  be  obtained  from  support 
rendered  by  means  of  a  light  and  well-fitting  pessary,  the  elastic 
ring  of  Meigs  if  there  be  merely  direct  descent ;  Hodge's  double 
lever  or  one  of  its  varieties  if  there  be  retroversion ;  or  an  antever- 


TEEATMENT.  299 

sion  pessary  if  the  uterus  liave  fallen  forwards.  In  some  cases  the 
benetit  derived  from  these  instruments  will  be  the  chief,  perhaps  the 
only  relief  which  we  can  bestow,  and  even  where  we  cannot  cure  the 
disease  we  may  by  their  use  render  life  much  more  agreeable  by 
the  alleviation  of  discomfort. 

If  evidences  of  fungoid  growths  on  the  endometrium  exist,  the 
whole  cavity  should  be  gently  scraped  by  the  wire-loop  curette, 
and  this  source  of  leucorrhcea,  metrorrhagia,  and  uterine  congestion 
taken  away. 

At  the  same  time  that  I  have  elsewhere  urged  that  too  great 
importance  should  not  be  given  to  granular  and  cystic  degeneration 
of  the  cervix,  I  would  not  ignore  the  fact  that,  once  established, 
they  become  a  source  of  irritation,  and  thus  of  uterine  engorge- 
ment.    They  should  by  all  means  be  treated  and  removed. 

Vaginitis  is  secondary  to  uterine  catarrh,  which  is  a  very  com- 
mon accompaniment  of  hyperplasia.  It  should  be  treated  by  the 
ordinary  means  elsewhere  indicated,  and  a  recurrence  prevented  by 
relief  of  the  endometrial  disease. 

The  subject  carefully  analyzed  presents  itself  in  this  way.  If 
the  abnormal  condition,  which  has  created  areolar  hyperplasia,  has 
passed  away,  this  condition  is  not  in  itself  the  source  of  many  dis- 
agreeable symptoms.  No  woman  thus  aifected  feels  perfectly  well, 
but  she  is  often  sufficiently  comfortable  to  be  able  to  perform  all 
her  duties  in  life.  But  the  uterus  thus  diseased  is  peculiarly  liable 
to  certain  complicating  conditions  which  have  just  been  mentioned, 
and  these  create  a  great  deal  of  discomfort  by  production  of  pains 
in  the  back  and  loins,  nervousness,  leucorrhcea,  and  menstrual  dis- 
orders. These  symptoms  are  then  in  a  great  degree,  as  I  stated  in 
giving  the  symptomatology  of  hyperplasia,  due  to  the  complications 
of  the  disorder,  and  not  to  the  disorder  itself.  In  other  words, 
sustain  a  hyperplastic  uterus,  keep  it  free  from  displacement, 
granular  and  cystic  disease  of  the  cervix,  and  uterine  catarrh,  and 
the  patient  will  be  so  comfortable  as,  in  most  instances,  to  feel 
satisfied  with  her  condition.  Sometimes  this  is  all  that  we  can 
accomplish.  The  mere  fact  of  accomplishing  these  results  will, 
however,  do  much  for  the  cure  of  the  disease  itself.  Relief  of  dis- 
placement favors  free  venous  return  and  prevents  congestion  which 
feeds  and  perpetuates  hyperplasia.  Cure  of  uterine  catarrh  and  of 
granular  and  cystic  degeneration  of  the  cervix  removes  two  great 
causes  for  hypertemia  of  mucous  and  submucous  tissues.  The 
means  employed  for  the  relief  of  these  symptoms  even  do  more, 
they  tend  by  their  own  direct  influence  to  alter  the  morbid  state 


300        AREOLAR    HYPERPLASIA    OR    CHRONIC    METRITIS. 

of  the  nerves  of  the  part,  to  diminish  the  calibre  of  bloodvessels 
under  their  control,  and  thus  to  check  excessive  nutrition  and 
secretion. 

All  complications  being  removed,  the  practitioner  has  now  to  deal 
with  a  large,  heavy  uterus,  the  tissue  of  which  is  exuberant,  the 
bloodvessels  enlarged,  and  the  nerves  in  a  condition  of  hypersesthe- 
sia. 

Let  me  enumerate  the  indications  to  be  met  by  a  few  leading 
propositions. 

1st.  Everything  possible  should  be  done  to  prevent  congestion, 
and  remove  that  already  existing. 

2d.  Every  attention  should  be  given  to  the  restoration  of  the 
general  system,  especially  the  blood  and  nerve  states. 

3d.  All  weight  should  be  taken  from  the  large  and  heavy  uterus. 

4th.  Nervous  hypersesthesia  should  be  relieved  by  ever^-  means 
in  our  power. 

The  means  for  furthering  these  ends  may  thus  be  presented : 

Rest ; 

General  treatment ; 

Depletion ; 

Emollient  vaginal  injections; 

Alteratives. 

Rest. — The  patient  sliould  be  instructed  to  take  much  less  exer- 
cise than  usual,  to  lie  upon  her  bed  or  lounge  for  an  hour  every  day 
about  mid-day,  and  to  be  especially  quiet  during  menstrual  periods. 
It  is  highly  improper  to  confine  her  to  bed,  for  many  women  become 
restive  under  the  confinement,  and  suffer  both  in  mind  and  body, 
the  sanguineous  and  nervous  systems  being  impaired  by  want  of 
fresh  air.  If  the  connective  tissue  be  so  much  affected  that  the 
cervix  is  very  painful  upon  pressure,  absolute  rest  upon  the  back 
may  become  necessary,  but  my  impression  is  that  deprivation  of 
fresh  air  and  exercise  ordinarily  does  more  harm  than  is  compen- 
sated for  by  the  advantages  arising  from  quietude.  Every  day  she 
should  go,  unless  deterredtby  some  special  cause,  into  the  open  air, 
and  a  limited  amount  of  exercise  should  be  inculcated  as  a  means 
of  keeping  up  the  general  health. 

The  uterus  should  be  placed  at  rest  as  much  as  possible.  Its 
natural  tendency  under  these  circumstances  is  to  fall  from  its  posi- 
tion, consequently  all  pressure  should  be  removed  from  its  fundus 
by  the  use  of  a  skirt  supporter  and  a  ^^'ell  fitting  abdominal  Ijandage. 
Fig.  80  represents  a  very  excellent  skirt  supporter,  which  has  been 


TREATMENT, 


301 


Bacheller's  skirt  supporter,  the  circu- 
lar piece  a  thin  baud  of  metal. 


patented  by  Mr.  Bacheller.     Ab-  Fior.  80. 

dominal  bandages  are  very  unpopu- 
lar with  many  practitioners,  who 
believe  that  .they  absolutely  do 
harm.  I  believe  otherwise,  and 
regard  them  as  great  adjuvants, 
not  in  keeping  up  the  uterus,  but 
in  supporting  the  super-imposed 
viscera,  which,  pressed  downwards 
by  tight  clothing,  and  badly  su}> 
ported  on  account  of  the  relaxa- 
tion of  the  abdominal  walls,  fall 
directly  upon  the  fundus.  There 
is  a  great  variety  of  abdominal 
supporters.  I  have  no  favorite,  for 
one  will  accomplish  the  end  in  a  woman  of  a  certain  figure  which 
would  be  inappropriate  for  another.  That  one  should  be  selected 
which  absolutely  accomplishes  the  end  in  view,  namely,  sustaining 
the  viscera  and  supplementing  the  weakened  muscles  of  the  abdo- 
men. 

Sexual  intercourse  often  produces  bad  results  in  an  organ  which 
is  so  prone  to  congestion,  and  great  infrequency  and  caution  should 
be  enjoined  with  reference  to  it. 

"By  combining  all  these  means  we  do  all  in  our  power  to  place 
the  hyperplastic  uterus  at  rest  as  we  would  a  fractured  bone  or 
enlarged  testicle. 

General  Treatment. — The  diet  should  be  plain  and  unstimulating, 
but  at  the  same  time  nutritious,  and  in  every  way  calculated  to 
maintain  the  normal  state  of  the  blood.  Should  spansemia  exist, 
ferruginous  tonics,  alone  or  combined  with  vegetable  tonics,  should 
be  administered.  The  bowels  should  be  kept  in  a  perfectly  normal 
state,  and  the  skin  active.  Specific  remedies  have  been,  and  are 
still,  employed  by  some  practitioners  for  diminishing  the  size  of 
the  uterus.  Of  most  of  these  I  doubt  the  efficacy.  During  the 
stage  of  enlargement,  that  is,  before  contraction  of  the  exuberant 
tissue  has  occurred,  ergot,  kept  up  for  a  considerable  time,  produces 
good  results.  By  its  power  of  exciting  contraction  of  the  uterine 
tissue  it  diminishes  hypersemia,  and  lessens  the  bulk  of  the  uterus. 

European  writers  speak  in  high  terms  of  the  alterative  influences 
of  the  various  watering-places  and  baths  of  the  Continent,  as  those 
of  Marienbad,  Schwalbach,  Briicknau,  and  Kissingen,  in  Germany, 
and  of   Saint  Sauveur,  Bareges,  etc.,  in  Switzerland.      None  of 


302        AREOLAR    HYPERPLASIA    OR    CHRONIC    METRITIS. 

these  equal  in  reputation  the  waters  of  Kreuznach  in  Germany, 
the  curative  property  of  which  is  supposed  to  depend  upon  the 
bromide  of  magnesium  which  they  contain.  It  is  very  probable 
that  the  hygienic  and  social  influences  which  surround  these  places 
and  render  them  attractive,  are  to  be  credited  with  all  the  good 
that  they  do.  Aran,  after  admitting  that  the  water  of  Vichy  nuni 
exert  some  influence,  thus  pointedly  expresses  himself  with  refer- 
ence to  the  others :  "  Whatever  be  their  composition,  in  whatever 
countries  they  may  be  found,  I  know  of  no  work  in  which  we  can 
find  an  approximation  to  a  demonstration  in  their  favor." 

No  other  general  means  compares  in  result  with  a  change  of 
abode  and  corresponding  change  of  air,  habits,  and  associations. 
A  removal,  for  example,  to  the  seaside,  where  bathing  can  be 
enjoyed,  a  sea  voyage,  or  a  residence  at  an  agreeable  watering  place, 
may  accomplish  much  good.  Mental  depression  predisposes  to  and 
aggravates  this  disease  most  markedly.  Aran  goes  so  far  as  to  say 
that  he  has  almost  invariably  found  it  present  as  an  exciting  cause. 
However  this  be,  cheerful  and  congenial  compan}'^  certainly  proves 
one  of  the  best  nervous  tonics  in  a  therapeutic  point  of  view,  and 
should  always  be  sought  for.  A  stay  in  a  well  regulated  hydro- 
pathic establishment,  where  the  patient  can  have  pure  air,  plain 
and  nutritious  food,  and  agreeable  society,  together  with  the  strict 
attention  to  the  general  rules  of  hygiene  which  characterizes  those 
institutions,  will  often  prodtice  the  best  effects. 

Depletion. — If  vaginal  touch  and  conjoined  manipulation  discover 
the  fact  that  the  uterus  is  tender,  the  occasional  abstraction  of 
small  amounts  of  blood  by  puncture  or  scarification  will  be  bene- 
ficial. Not  more  than  an  ounce  or  two  should  be  taken  at  once, 
unless  amenorrhoea  be  a  symptom.  In  case  this  be  so,  a  more  copious 
abstraction  by  leeches,  during  the  menstrual  epoch,  will  often  give 
great  relief.  At  times  leeches  then  applied  to  the  cervix  will 
give  great  pain  l)y  their  bites.  This  is  sometimes  so  severe  as  to 
lead  to  the  apprehension  that  one  has  escaped  into  the  cavity; 
hence  it  is  important  that  they  should  be  counted  before  being 
placed  in  the  speculum,  and  on  their  removal  from  it. 

The  three  methods  by  which  local  depletion  of  the  cervix  can  be 
best  practised  are  leeching,  scarification,  and  cupping.  Three  or  four 
large  leeches,  or  a  sufficient  number  of  small  ones,  to  take  from  three 
to  five  ounces  of  blood,  may  be  applied  in  the  following  manner:  a 
cylindrical  speculum,  of  sufficient  size  to  contain  the  entire  vaginal 
portion  of  the  cervix,  being  passed  and  the  part  thoroughly  cleansed, 
a  small  pledget  of  cotton,  to  w±ich  a  thread  has  been  attached  for 


DEPLETION.  303 

removal,  should  be  placed  within  the  os,  so  as  to  prevent  the  en- 
trance of  the  leeches  to  the  cavity  above.  A  few  slight  punctures, 
sufficient  to  cause  a  flow  of  blood,  should  then  be  made  in  the 
cervix,  and  all  the  leeches  to  be  employed  thrown  in,  and  the 
speculum  filled  at  its  extremity  by  a  dossil  of  cotton  pushed  towards 
the  bleeding  surface.  The  speculum  should  be  watched  until  they 
cease  sucking,  for  if  left  for  a  very  short  time,  even  with  the  mouth 
of  the  instrument  filled  with  cotton,  they  will  escape.  After  their 
removal  all  clots  of  blood  should  be  removed  by  a  sponge  or  a  rod 
wrapped  with  cotton,  the  speculum  withdrawn,  a  large  sponge 
squeezed  out  of  warm  water  placed  over  the  vulva,  and  the  patient 
directed  to  remain  perfectly  quiet.  Should  scarification  be  em- 
ployed, a  very  sharp  and  narrow  bistoury  or  tenotomy  knife  may 
be  introduced  within  the  os,  and  drawn  outward  towards  the  vagi- 
nal edges  of  the  cervix  so  as  to  sever  all  the  superficial  vessels  over 
which  it  passes.  I  would  recommend,  in  preference  to  this  plan, 
acupuncture,  which  may  be  performed  by  an  ordinary  three-sided 
surgical  needle  held  in  the  grasp  of  a  pair  of  forceps,  or  still  better, 
by  a  little  spear,  the  invention  of  Dr.  Buttles,  of  this  city. 

Fig.  81. 


Bnttles's  spear-pointed  scarificator. 

This  little  instrument,  when  plunged  about  one-sixteenth  of  an 
inch  into  the  cervix  and  given  a  rapid  half  turn  before  removal, 
causes  a  very  free  flow  of  blood  should  congestion  exist.  If  a 
sufficient  flow  does  not  occur  from  three  or  four  of  its  punctures, 
this  can  be  caused  by  dry  cupping  the  cervix  by  a  very  simple 
instrument,  made  of  vulcanite,  which  is  introduced  through  the 
speculum,  the  medium  size  of  the  cylindrical  variety  being  large 
enough  to  admit  it.  Being  passed  up  to  the  cervix,  the  piston  is 
retracted,  and  so  perfect  is  the  working  of  these  instruments, 
when  constructed  of  vulcanite,  that  a  complete  vacuum  is  pro- 
duced. By  using  this  for  a  few  minutes,  and  then  puncturing, 
with  Buttles's  spear,  from  two  to  four  ounces  of  blood  may  readily 
be  drawn.  The  exhauster  should  not  be  used  after  puncturing, 
but  before  it.  All  that  will  be  necessary  afterwards  will  be  to  pass 
a  moist  sponge,  attached  to  a  sponge-holder,  over  the  punctured 
surface  so  as  to  prevent  clotting  in  the  mouths  of  the  bleeding 
vessels.  Dr.  John  Byrne,  of  Brooklyn,  has  recently  drawn  espe- 
cial attention  to  still  another  method,  which  in  some  cases  answers 


304       AREOLAR    HYPERPLASIA    OR    CHRONIC    METRITIS. 


an  excellent  purpose.  It  consists  in  passing  a  long,  delicate  blade 
up  to  the  OS  internum,  and  cutting  through  the  mucous  membrane, 
its  bloodvessels,  and  the  superficial  layer  of  muscular  tissue,  as  it  is 
withdrawn  through  the  os  externum.  Local  depletion  by  one  of 
these  methods  should  be  practised  systematically,  the  patient  for 
some  hours  after  its  adoption  being  kept  perfectly  quiet  in  bed. 

Fig.  82. 


Davidson's  Syringe. 


Hard  rubber  cylinder  for  dry  cupping  the  cervix  uteri. 

Vaginal  Injections. — To  be  efficient  they  should  be  copious  and 
long  continued.  There  are  four  methods  of  employing  them  whicli 
I  should  recommend.  Placing  in  a  tub  from  one  to  two  gallons 
of  water,  at  as  high  a  temperature  as  proves  comfortable  to  the 
patient,  she  may  sit  over  it  upon  a  board  ];»laced  across  it,  or  upon 
a  stool  placed  in  it,  and  inject  the  water  by  means  of  a  syringe. 
The  most  convenient  syringes  for  the  purpose 
Fig.  83.  are  the  Essex  and  Davidson's.     Both  of  these 

are  provided  with  a  stem  about  five  inches  long, 
wliich  being  introduced  into  the  vasfina  and 
carried  up  so  as  to  touch  the  cervix,  throws, 
when  the  ball  of  the  instrument  is  compressed 
by  the  disengaged  hand  of  the  patient,  a  steady 
stream  against  it.  By  this  means  a  stream  of 
warm  water  is  made  to  pour  over  the  cervix  for  from  twenty  to 
thirty  minutes,  according  to  the  amount  of  fatigue  which  the  use 
of  the  instrument  causes  the  patient.  This  is  a  good  plan  in  case 
the  patient  is  so  circumstanced  as  not  to  be  able  to  assume  the 
recumbent  posture  while  using  the  injection.  That  position  adds 
greatly  to  the  efficiency  of  the  means,  and  really  involves  no  amount 
of  trouble  or  annoyance.  The  patient  should  lie  upon  a  lounge  or 
low  bed,  with  the  buttocks  projecting  over  its  edge,  and  the  feet 
supported  upon  the  floor  or  upon  two  chairs.  An  empty  vessel 
should  be  placed  on  the  floor  to  catch  the  water  escaping  from  the 
vagina.  "While  lying  thus,  an  excellent  method  of  employing  the 
injection  is  this:  an  ordinary  tub  or  bucket,  near  the  bottom  of 
which  a  stopcock  has  been  inserted  connecting  with  an  India- 
rubber  or  gutta-percha  tube  about  five  or  six  feet  long  with  a 
metallic  stem  like  that  of  the  Davidson  syringe  at  the  end,  is 
placed  upon  an  elevation,  as,  for  example,  a  chair  placed  upon  a 


VAGINAL    INJECTIONS. 


305 


table,  or  a  shelf  made  for  the  purpose.  The  vaginal  stem  being 
inserted,  the  cock  is  turned  by  the  patient,  and  for  half  an  hour  a 
stream  of  water  freely  bathes  the  inflamed  part,  and  passing  out 
of  the  vagina,  pours  into  the  tub  over  which  the  patient  is  lying. 
This  avoids  all  fatigue,  and  produces  a  much  more  prolonged  appli- 
cation. This  can  likewise  be  conveniently  done  by  means  of  the 
Fountain  syringe,  which  consists  of  a  large  bag  of  gutta-percha 
which  holds,  according  to  the  size,  from  one  to  three  quarts  of 
water.  This  bag,  communicating  at  its  bottom  with  a  long  tube 
made  of  the  same  material,  is  filled  and  hung  up.  Then  the  patient, 
passing  into  the  vagina  the  nozzle  connected  with  the  lower  end 
of  the  long  flexible  tube,  touches  a  spring,  and  the  fluid  flows  by 
gravitation. 

This  syringe  can  be  packed  in  small  compass,  and  is  very  con- 
venient and  manageable. 

Fig.  84  represents  Molesworth's  vaginal  syringe,  an  excellent 
instrument  for  cleansing  and  medicating  the  vagina  and  cervix 

Fig.  84. 


Molesworth's  vaginal  syringe. 


uteri.  It  consists  of  a  small  glass  speculum  attached  to  a  bag  of 
India-rubber.  The  former  being  introduced  to  the  upper  j)art  of 
the  vagina,  and  the  latter  filled  with  fluid,  it  is  repeatedly  com- 
pressed so  as  to  bathe  the  canal  thoroughly. 

Lastly,  the  patient  may  take  a  warm  hip-bath,  or  entire  bath, 
night  and  morning,  and  use  the  vaginal  injection  while  in  the 
l)ath.  This  method  possesses  the  additional  advantages  to  be  de- 
rived from  general  and  hip-baths  in  the  treatment  of  these  cases. 
If  the  patient  cannot  be  moved  in  bed  without  inconvenience,  the 
Davidson's  syringe  may  be  employed,  while  she  is  lying  in  bed 
with  the  bedpan  under  the  buttocks  to  receive  the  escaping  fluid. 

Warm  water  is  the  best,  as  it  is  the  simplest,  most  attainable, 
and  cleanest  of  all  the  emollients  which  can  be  used  for  this  pur- 
pose. But  it  may  easily  be  medicated  by  the  addition  of  lauda- 
20 


306       AREOLAR    HYPERPLASIA    OR    CHRONIC    METRITIS. 

num,half  an  ounce  to  the  gallon ;  infusions  of  linseed,  poppies,  hops, 
bran,  slippery  elm,  starch,  hyoscyamus,  conium,  or  farina ;  or  by 
the  addition  of  glycerine,  one  ounce  to  the  gallon,  lime-water  or 
tar-water,  both  of  which  last  are  often  very  soothing  to  vaginitis 
that  may  exist  as  a  complication. 

Local  Alteratives. — The  best  local  alterative  is  ihe  compound 
tincture  of  iodine,  which,  by  means  of  a  brush  of  pig's  bristles, 
should  l)e  carried  up  to  the  os  internum,  or  even  to  the  fundus, 
should  endometritis  exist,  and  over  the  whole  cervix ;  then,  wait- 
ing for  complete  drying,  this  process  should  be  repeated.  After 
these  applications  a  wad  of  cotton,  to  which  a  string  has  been 
attached  in  such  a  way  as  to  leave  its  surface  flat,  should  be  satu- 
rated with  glycerine  and  laid  against  the  cervix.  This  acts  as  a 
local  hydragogue,  and  disgorges  the  tissues.  These  local  applica- 
tions should  be  repeated  once  a  week,  but  others  should  be  made 
oftener  by  the  patient  herself  by  means  of  vaginal  injections,  by 
which  the  drugs  just  mentioned  may  be  brought  in  contact  with 
the  cervix. 

Mild  and  lacking  in  vigor  as  this  course  may  appear,  let  any  one 
test  it  side  by  side  with  the  plan  of  using  the  acid  nitrate  of  mercury, 
potassa  fusa,  and  potassa  cum  calce,  and  the  actual  cautery  ;  of 
swabbing  out  the  uterine  cavity  with  chemically  pure  nitric  acid, 
or  of  leaving  a  piece  of  solid  nitrate  of  silver  to  melt  within  it; 
and,  unless  his  experience  greatly  differ  from  mine,  he  will  feel  that 
in  the  former  he  has  readied  a  resting  place  for  his  faith  in  the 
treatment  of  the  most  important  of  all  the  forms  of  uterine  disease. 
He  will  see  proof  daily  spring  up  before  him  that  his  capacity  for 
benefiting  his  patients  has  greatly  increased,  while  his  liability  to 
injuring  them  has  as  markedly  diminished. 

Should  it  appear  to  the  practitioner  that  persistent  hyperoemia 
requires  more  energetic  means  than  those  mentioned,  resort  may  be 
had  to  counter-irritants  which  vesicate  and  destroy  the  mucous 
membrane  of  the  vaginal  cervix,  and  thus  cause  a  free  flow  of 
serum.  Such  cases  grow  smaller  and  smaller  in  number  in  my 
practice  as  I  grow  older  in  experience,  and  although  I  admit  the 
occasional  necessity  of  these  means,  I  caution  the  reader  against  a 
constant  or  too  early  resort  to  their  use.  They  cannot  diminislj 
the  absolute  size  of  the  enlarged  organ,  and  should  not  be  used 
with  any  such  view.  They  can  remove  congestion  and  nervous 
exaltation,  and  in  certain  exceptional  cases  may  be  employed  for 
these  purposes. 

One  of  the  best  methods  for  practising  counter-irritation  upon 


LOCAL    ALTERATIVES.  307 

the  cervix  uteri  is  by  blistering,  a  means  for  wliich  we  are  indebted, 
I  believe,  to  Aran,  of  Paris.  To  blister  the  cervix,  a  large  cylin- 
drical speculum  should  be  used  which  will  take  the  whole  part 
into  its  field.  The  cervix  having  been  cleansed  and  dried  by  a  soft 
sponge  or  dossil  of  cotton,  a  camel's-hair  brush  is  dipped  into 
vesicating  collodion,  which  consists  of  ordinary  collodion,  com- 
monly known  as  liquid  cuticle  in  this  country,  containing  in  sus- 
pension cantharides,  and  painted  over  the  whole  vaginal  cervix,  no 
effort  being  made  to  avoid  the  os.  There  are  two  preparations  of 
vesicating  collodion,  one  made  with  ether,  the  other  with  acetic 
acid.  The  second  is  the  more  powerful  and  the  less  likely  to  affect 
the  vagina.  In  a  few  seconds  after  it  is  painted  on  the  cervix,  it 
forms  a  hard,  insoluble  covering,  upon  which  two  or  three  other 
coats  may  be  at  once  applied.  The  whole  is  then  exposed  to  the 
air  by  keeping  the  speculum  in  place  for  a  few  minutes,  a  stream 
of  cold  water  projected  upon  it,  to  prevent  any  escape  into  the 
vagina,  and  the  process  is  finished.  In  from  eight  to  twelve  hours 
the  epithelial  covering  of  the  cervix  is  entirely  removed  by  this, 
and  a  free  flow  of  serum  takes  place  as  from  a  blister  elsewhere 
applied.  After  this  the  patient  should  be  kept  perfectly  quiet  for 
several  days,  cleansing  the  vagina  by  warm  injections,  and  as  soon 
as  the  discharge  shows  a  tendency  to  cessation,  the  blistering  should 
be  repeated.  The  only  objections  to  this  method  of  counter-irrita- 
tion are  the  liability  to  vaginitis  and  cystitis  from  escape  of  the 
blistering  fluid  into  the  vagina  and  mouth  of  the  urethra,  which 
can  readily  be  avoided,  and  the  pain  which  is  experienced  in  some 
cases  while  vesication  is  taking  place. 

After  blistering,  pledgets  of  cotton  saturated  with  glycerine 
should  be  applied  for  the  hydragogue  effects  of  that  drug. 

Vesication  may  be  easily  produced  by  still  another  method, 
which  is  both  effectual  and  simple.  By  means  of  a  solid  stick  of 
nitrate  of  silver,  which  is  rubbed  gently  over  the  whole  vaginal 
portion  of  the  cervix,  its  epithelial  covering  is  destroj'ed,  soon 
sloughs  oft*,  and  leaves  a  granulating  surface,  which  may  be  dressed 
with  any  of  the  alterative  substances  mentioned  above,  or  with 
glycerine. 

It  is  a  well  ascertained  fact  that  when  a  superficial  layer  of  an 
organ  which  is  affected  by  hypertrophy  is  cut  off",  a  marked  ten- 
dency to  diminution  in  the  bulk  of  the  remaining  tissue  shows 
itself.  Thus,  for  example,  in  that  areolar  hyperplasia  which  affects 
the  tonsils,  if  only  the  faces  of  these  bodies  be  shaved  oft'  by  the 


308       AREOLAR    HYPERPLASIA    OR    CHRONIC    METRITIS. 

knife,  the  remainder  becomes  diminished  in  size.  The  same  thing 
holds  true,  although  by  no  means  to  the  same  degree,  in  the  uterus. 
Dr.  Sims  was,  I  believe,  the  first  to  propose  this  plan.  It  has  since 
been  adopted  by  others,  and  constitutes  a  valuable  method  for 
meeting  the  requirements  of  some  very  unmanageable  cases,  in 
which  the  large  size  of  the  cervix  renders  it,  by  its  bulk,  a  source 
of  discomfort  to  the  woman.  The  same  grounds  should  decide  the 
gynecologist  to  operate  here,  as  do  the  surgeon  in  enlarged  tonsils ; 
not  the  mere  existence  of  enlargement  in  the  organ,  but  the  fact 
that  this  enlargement  disturbs  other  parts  by  its  degree,  or  that  all 
other  means  failing  to  cause  reduction  in  its  size,  this  offers  itself  as 
a  means  of  accomplishing  that  result.  I^o  great  amount  of  tissue 
need  be  removed.  By  a  pair  of  straight  scissors,  the  cervix  is  slit 
to  the  extent  of  one-fourth  of  an  inch ;  then  by  means  of  a  pair 
curved  laterally,  almost  at  a  right  angle,  the  lower  extremities  of 
the  lips  are  cut  off".  A  raw  and  bleeding  surface  is  thus  left 
exposed,  and  the  suppurative  action  set  up  in  this  seems  to  act  as 
a  drain  upon  the  uterus. 

The  operation  may  be  much  better  accomplished  by  means  of 
galvano-cautery.  The  vaginal  portion,  or  rather  a  part  of  the 
vaginal  portion  of  the  cervix,  is  encircled  by  the  galvano-caustic 
wire,  and  thus  removed. 


GJtiANULAB    DEGENERATION    OF    THE    CERVIX.  309 


CHAPTER   XVII. 

GRANULAR  AND   CYSTIC    DEGENERATION  OF   THE  CERVIX  UTERI. 

It  not  unfrequently  happens  that  one  symptom  of  a  disease  will 
so  distress  and  harass  a  patient  that  remedial  measures  must  be 
entirely  directed  to  it,  although  the  practitioner  be  aware  of  the 
fact  that  it  depends  on  diseases  elsewhere  located.  An  example  of 
this  is  frequently  presented  in  the  morbid  state  under  consideration, 
which,  in  itself,  j)roves  so  annoying  by  its  profuse  discharge,  and 
interference  with  the  functions  of  the  uterus  and  with  locomotion, 
as  to  call  for  prompt  relief. 

The  vaginal  surface  of  the  cervix  uteri  is  covered  by  a  smooth 
mucous  membrane  which  is  continuous  below  with  that  of  the 
vagina,  and  extending  through  the  cervical  canal  joins  that  of  the 
body,  which  differs  widely  from  it,  at  the  os  internum.  This  mem- 
brane is  covered  over  by  numerous  papillae  which  become  visible 
when  a  sufficiently  strong  glass  is  used.  One  or  more  slender  blood- 
vessels pass  into  each  and  form  at  their  extremities  vascular  loops, 
then  return,  and  at  their  bases  pass  into  adjoining  ones.  They  are 
completely  covered  by  pavement  epithelium  and  basement  mem- 
brane. Throughout  the  cervical  canal  mucous  crypts  or  follicles  exist, 
which  are,  likewise,  found  scattered  over  the  vaginal  portion  of  the 
cervix,  and  even  within  the  cavity  of  the  uterus  itself.  The 
diseases  of  two  of  these  elements  of  cervical  mucous  membrane,  the 
villi  and  mucous  crypts,  are  now  to  engage  our  attention. 

Granular  Degeneration  of  the  Cervix. 

Definition. — This  condition,  which  has  been  described  under  the 
names  of  erosion  of  the  cervix,  granular  ulcer,  and  epithelial  abra- 
sion, consists,  as  its  name  implies,  in  the  development  of  a  surface 
of  granular  character  on  the  smooth  face  of  the  cervix  and  just 
within  the  os. 

Frequency. — It  is  an  affection  of  great  frequency,  attending  all 
the  diseases  of  the  uterus  which  result  in  leucorrhoea,  and  being 
commonly  a  concomitant  of  most  of  the  diseased  conditions  of  the 


310  GEANULAR    AND    CYSTIC 

parenchyma  and  lining  membrane.  Very  often  it  exists  for  a 
length  of  time  without  any  suspicion  of  its  presence  arising  in  the 
mind  of  patient  or  physician,  and  sometimes  without  causing 
symptoms  which  prove  in  any  great  degree  annoying.  At  others, 
grave  constitutional  signs  may  be  traced  to  it  and  entirely  removed 
by  its  cure. 

Causes. — The  predisposing  causes  are: 

Enfeebled  general  health ; 

Spansemia ; 

The  scrofulous  diathesis; 

The  syphilitic  diathesis. 

Those  which  are  exciting  are  the  existence  of: 
Displacements ; 
Endometritis ; 
Laceration  of  cervix ; 
Areolar  hyperplasia ; 
Abuse  of  sexual  intercourse ; 
Vaginal  leucorrhoea ; 
Pessaries  which  touch  the  vaginal  face  of  the  cervix. 

From  this  array  of  causes  it  will  appear  that  it  is  rarely  a  disease 
which  stands  alone,  but  that  it  is  usually  engrafted  upon  some  other 
aftection  of  greater  moment.  Although  this  is  true,  it  will  not  do 
in  practice  to  carry  the  view  too  far.  At  the  same  time  that  it 
must  be  admitted  that  granular  desreneration,  even  of  asrs-ravated 
character  and  considerable  proportions,  affecting  the  vaginal  face 
of  the  cervix,  and  the  distal  extremity  of  the  cervical  canal,  is 
commonly  a  consequence  of  some  pre-existing  disease,  the  fact  must 
not  be  lost  sight  of,  that  this  affection  of  itself  keeps  up  a  hyper- 
aemia  in  the  subjacent  and  neighboring  parts  of  the  uterus,  and 
even  extends  a  reflex  influence  to  the  ovaries. 

By  almost  all  writers  upon  this  subject  since  R^camier's  time, 
too  much  stress  has  been  laid  upon  the  theory  that  it  depends 
upon  an,  "indurated  and  hypertrophied  condition  of  the  paren- 
chyma of  the  cervix."  That  it  results  from  this  no  one  would 
deny,  but  it  is  equally  true  that  it  often  arises  from  other  causes, 
and  itself  induces  this  one.  In  general  terms  we  may  say  that  it 
is  usually  produced  by,  1st,  any  disorder  which  keeps  the  villi  of 
the  cervix  constantly  bathed  with  ichorous  fluids  for  a  length  of 
time;  2d,  by  anything  which  keeps  up  friction  against  the  cervix; 
3d,  by  any  influence  producing  and  perpetuating  congestion  of  the 
uterus.     Let  the  reader  turn  to  the  list  of  predisposing  causes  and 


DEGENEEATION    OF    THE    CERVIX    UTERI.  311 

he  will  see  tluit  they  are  just  such  as  to  favor  these  morbid  influ- 
ences, and  that  the  exciting  ones  are  those  which  absolutely  produce 
them.  For  example,  displacements  keep  up  congestion  of  paren- 
chyma and  mucous  membrane,  and  produce  uterine  leucorrhoea, 
and  cause  friction  between  the  -cervix,  thus  engorged  and  excoriated, 
and  the  vaginal  surface.  Hyperplasia  produces  displacement  with 
all  its  results,  furnishing  in  advance  a  tissue  peculiarly  prone  to 
hypememia,  and  already  abnormal  in  character.  Laceration  of  the 
cervix  is  a  fruitful  source  of  cervical  hyperplasia,  and  the  eversion 
of  mucous  membrane  which  attends  it  establishes  friction  which 
results  in  leucorrhoea  and  increase  of  hypersemia.  But  it  is  un- 
necessary to  apply  remarks  which  are  so  obvious  to  each  of  the 
causes  mentioned. 

Symptoms. — Should  granular  degeneration  exist  with  but  trivial 
disorder  of  the  uterus  of  any  other  kind,  very  few  symptoms  may 
be  present.  Indeed,  profuse  leucorrhoea  is  sometimes  the  only  one 
of  which  the  patient  will  complain.  The  fact  that  other  and  more 
serious  symptoms  generally  show  themselves,  is  a  corroboration  of 
the  statement,  that  graver  disease  of  the  uterus  constitutes  an 
important  element  in  such  cases.  Ordinarily,  these  are  the  symp- 
toms which  will  be  noticed  in  a  case  of  the  more  serious  kind : 

Profuse  bloody  and  purulent  leucorrhoea ; 

Pain  and  hemorrhage  after  intercourse; 

Menorrhagia  or  metrorrhagia; 

Pain  on  locomotion; 

Fixed  pain  in  back  and  loins ; 

Tendency  to  spansemia; 

Nervous  disorders.and  perhaps  hysteria. 

Physical  Signs. — Vaginal  touch  alone  might  serve  as  a  diagnos- 
tic means,  for  by  it  the  cervix  is  felt  to  be  covered  by  a  velvety 
or  granular  surface,  which,  to  the  practised  finger,  is  at  once 
recognizable.  But  the  speculum  offers  the  fullest  corroboration  or 
corrects  any  error  committed  by  this .  means.  By  it,  the  cervix, 
more  especially  near  the  os,  is  seen  to  be  covered  by  a  mass  of  pus, 
which  being  removed  lays  bare  an  intensely  red,  granular,  hemor- 
rhagic-looking  space  of  greater  or  less  extent,  closely  resembling 
the  inner  surface  of  the  eyelids  when  affected  by  granular  degene- 
ration. The  diseased  surface  does  not  appear  depressed  below,  but- 
is  sometimes  even  elevated  above  the  surroundins:  mucous  mem- 
brane. 

Course  and  Duration. — The  disease  is  unlimited.     If  the  general 


312  GRANULAR    AND    CYSTIC 

healtli  improve,  it  is  possible  that  nature  may  effect  a  cure  without 
the  aid  of  local  treatment,  but  such  a  result  should  not  be  antici- 
pated. The  degenerated  surface  may  go  on  for  an  unlimited  time 
pouring  out  pus,  and  thus  greatly  impoverish  the  blood  and  cause 
grave  constitutional  results. 

Pathology. — Granular  degeneration  is  produced  by  one  of  three 
pathological  changes  in  the  tissues  of  the  part :  removal  of  epithe- 
lium and  erosion  of  villi ;  removal  of  epithelium  and  hypertrophy 
of  villi ;  eversion  of  the  cervical  mucous  membrane.  In  the  first 
instance,  the  epithelial  covering  is  first  removed,  producing  what 
is  called  an  abrasion,  and  the  villi  themselves  are  destroyed.  In 
the  second,  after  the  removal  of  the  epithelium,  the  papillae  or  villi 
increase  in  size  and  length,  and  project  forwards  like  granulations, 
the  larger  ones  so  compressing  the  smaller  as  to  cause  tlieir  death 
by  atrophy.  Each  of  these  papillae  contains  a  looped  capillary 
vessel  which,  becoming  enlarged  by  its  hypertrophy,  and  ])eing 
entirely  unprotected  by  ei)itliclium,  naturally  tends  to  bleed 
Sometimes  the  circulation  in  the  supplying  vessels  is  so  much 
impeded  that  they  become  varicose.  These  two  facts  have  caused 
the  names  of  bleeding  ulcer  and  varicose  ulcer  to  be  applied  to  the 
respective  states. 

At  times  still  another  change  occurs  in  this  condition,  giving 
rise  to  another  name.  Its  surface  becomes  coated  with  false  mem- 
brane, when  it  is  termed  a  diphtheritic  ulcer. 

Eversion  of  the  cervix  is  by  no  means  a  rare  source  of  granular 
degeneration.  As  a  result  of  prolonged  congestion  and  hyperplasia 
of  the  submucous  tissues,  or  in  consequence  of  laceration  of  the 
walls  of  this  canal  by  the  act  of  parturition,  its  lining  membrane 
prolapses  as  the  mucous  membrane  of  the  eyelids  does  in  ectropion, 
and  if  not  diseased  at  the  time  of  displacement,  very  soon  becomes 
so.  At  times  the  hypertrophj^,  which,  under  these  circumstances, 
takes  place  in  the  crested  folds  of  the  everted  cervical  membrane, 
produces  so  great  a  degree  of  projection  as  to  have  caused  the 
appellations  of  fungus  ulcer  or  cock's-comb  granulation  to  be 
applied  to  it,  according  to  Dr.  Arthur  Farre,'  though  Scanzoni^ 
regards  this  as  merely  an-  exaggeration  of  the  villous  hypertrophy 
recently  mentioned. 

Prognosis. — The  prognosis  in  this  affection  is  always  good,  though 
it  may  require  a  great  deal  of  time  to  effect  a  cure,  for  this  will 


'  Supplement  Cyc.  Anat.  and  Phys.,  p.  695. 
^  Pis.  of  Females,  Am.  ed.,  p.  222. 


DEGEXERATIOX    OF    THE    CERVIX    UTERI.  313 

not  be  permanent  unless  that  of  the  coexisting  disease  be  accom- 
plished. 

Treatment. — Before  treatment  for  this  condition  is  commenced, 
let  me  urge  the  practitioner  to  examine  carefully  as  to  whether  he 
is  really  dealing  with  a  case  of  granular  degeneration  or  with  one 
of  cervical  laceration.  The  two  conditions  closely  resemble  each 
other;  the  former  often  complicates  the  latter;  and  a  treatment 
which  is  appropriate  to  the  one  is  utterly  insufficient  for  the  other. 

Granular  degeneration  being  generally  a  secondary  disorder 
engrafted  upon  a  pre-existing  one,  before  treatment  is  adopted,  the 
primary  disease  should  be  sought  for,  and  both  should  be  treated 
simultaneously. 

Should  displacement,  endometritis,  vaginitis,  or  areolar  hyperplasia 
exist,  attention  should  be  directed  to  their  relief  at  the  same  time 
that  this  one  of  their  results  is  treated.  It  may  be  asked,  if  this  be 
true,  how  is  it  that  the  mere  application  of  caustics  to  the  diseased 
surface  will  so  often  effect  a  recovery  without  regard  to  other  dis- 
ease? An  influence  which  commonly  induces  granular  degeneration 
is  disease  of  the  mucous  and  submucous  tissues  at  the  vaginal 
extremity  of  the  cervix.  The  solution  of  continuity  to  which  the 
caustics  are  applied,  acts,  after  their  application,  as  an  issue,  and 
they  by  derivative  and  alterative  influence  effect  good.  It  is 
precisely  in  accordance  with  this  principle  that  the  practitioner,  if 
called  to  treat  a  very  obstinate  case  of  cervical  hyperplasia,  which 
is  unattended  by  such  solution  of  continuity,  creates  it  by  abrading 
the  surface  by  a  blister,  and  then  cures  the  issue  thus  caused  by 
such  caustics  as  the  nitrate  of  silver  or  chromic  acid.  It  is  common 
to  hear  physicians  remark  that  they  are  more  successful  in  treating 
cases  of  cervical  enlargement  accompanied  by  granular  degeneration, 
than  those  which  are  free  from  it.  The  key  to  the  explanation  is, 
I  think,  the  one  here  given. 

Having  presented  these  remarks  and  sufficiently  insisted  upon 
their  importance,  I  now  proceed  to  the  consideration  of  the  special 
treatment  of  the  condition  itself.  Before  commencing  treatment, 
the  general  health  should  receive  especial  attention  ;  those  tonics 
and  hygienic  directions  which  appear  best  suited  to  the  particular 
case  being  given.  These  indications  should  from  the  commence- 
ment be  as  far  as  possible  fulfilled :  1st,  the  granular  surface  should 
be  put  beyond  the  influence  of  friction ;  2d,  it  should  be  protected 
from  contact  with  ichorous  discharges ;  3d,  a  steady  alterative  in- 
fluence should  be  exerted  upon  it  by  local  applications ;  and  4th, 


314  GRANULAR    AND    CYSTIC 

congestion  of  the  uterus  and  of  the  especial  part  diseased  should  be 
prevented. 

To  accomplish  the  first  indication  tlie  uterus,  if  displaced,  should 
be  put  and  kept  in  position  by  a  well-fitting  pessary.  Even  if  its 
axis  be  normal,  it  is  often  excellent  practice  to  lift  it  out  of  the 
pelvis  by  an  elastic  ring.  At  the  same  time  such  support  prevents 
a  tendency  to  congestion  of  the  organ,  and  may  be  rendered  more 
efi:ectual  by  careful  removal  of  all  weight  from  the  abdomen,  by 
tightly  fitting  or  heavy  clothing.  Let  no  one  who  has  not  tried 
this  as  an  adjuvant,  undervalue  it,  for  there  can  be  no  question  of 
its  great  utility. 

Free  use  of  copious  vaginal  injections  should  be  practised  twice 
daily,  to  remove  all  leucorrhoeal  discharge,  and  should  this  arise 
from  endometritis,  that  condition  should  be  treated.  This  indi- 
cation may  further  be  accomplished  by  the  application  of  the 
styptic  colloid  of  Richardson,  which  consists  of  a  strong  solution 
of  tannin  in  gun-cotton  collodion.  I  know  of  no  means  better  cal- 
culated than  this  to  accomplish  all  four  of  the  indications  enume- 
rated. It  appears  to  act  not  only  as  a  direct  alterative,  but,  forming 
a  protective  crust  over  the  surface,  constitutes  for  it  a  shield  against 
friction  and  uterine  discharges,  wliile  at  the  same  time,  by  its 
compression  of  the  excoriated  villi,  permeated  by  their  loojis  of 
vessels,  and  of  the  submucous  tissue  with  its  increased  vascular 
supply,  it  diminishes  local  congestion. 

The  nerves  governing  nutrition  and  circulation  in  the  part 
should  be  impressed  with  a  new  influence  by  direct  alterative 
applications.  The  best  solid  ones  are  the  stick  of  nitrate  of  silver 
or  sulphate  of  copper ;  and  the  most  efl:ectual  fluid  applications, 
saturated  solution  of  carbolic  acid;  chromic  acid  ^ss  to  water  .^j  ; 
compound  tincture  of  iodine;  equal  parts  of  tannin  and  glycerine, 
left  in  contact  with  the  ])art  on  jjledgets  of  lint  or  cotton ;  iodoform ; 
and  saturated  solution  of  persulphate  of  iron,  i)ure  or  diluted  with 
equal  parts  of  glycerine. 

It  is  a  good  routine  plan  to  begin  with  a  thorough  application  of 
solid  nitrate  of  silver,  and  follow  this  immediately  by  a  protective 
coating  of  styptic  colloid. 

When  an  exuberant  development  of  villi,  called  by  Evory  Ken- 
nedy, I  think,  cock's-comb  granulation,  exists,  it  is  well  to  snip 
the  growths  as  close  as  possible  to  the  mucous  membrane  by  a  pair 
of  long-handled  scissors,  or  even  to  scrape  the  surface  until  it  is 
smooth,  by  means  of  the  steel  curette,  before  applying  the  caustic. 


DEGENERATION    OF    THE    CERVIX    UTERI.  815 

After  this  the  same  substances  may  be  used  as  for  ordinary  granu- 
lar degeneration. 

Should  simple  eversion  of  the  cervix  exist,  the  hemorrhoidal 
mucous  membrane  should  be  at  once  removed  by  the  scissors  or 
destroyed  by  fuming  nitric  acid.  When  this  is  excessive,  and  due 
to  laceration  of  the  canal  by  parturition,  the  condition  may  be 
cured  by  an  operation  which  consists  in  paring  with  long  scissors 
the  edges  of  the  cervical  fissure,  and  passing  deep  sutures  of  silver 
wire  so  as  to  approximate  them  thoroughly.  By  this  means  the  os 
is  restored  to  its  integrity,  and  the  everted  mucous  surfaces  being 
placed  face  to  face,  friction  against  them  is  prevented. 

The  last  indication  in  enumeration,  but  not  in  importance,  is  the 
prevention  of  congestion,  local  and  general.  To  a  certain  extent 
this  is  accomplished,  locally,  by  all  the  alterative  and  astringent 
applications  alluded  to,  and  the  same  thing  may  be  furthered  by 
vaginal  suppositories  and  injections.  Should  any  case  prove  very 
obstinate,  this  end  may  be  more  decidedly  attained  by  taking  a 
sharp-pointed,  curved  bistoury,  and  beginning  as  high  up  the  cervix 
as  the  disease  extends,  cutting  through  the  mucous  membrane  and 
submucous  tissue,  extending  the  incision  outside  the  os  as  far  as 
the  surface  is  afi:ected.  Five  or  six  such  superficial  and  painless 
incisions  sever  the  network  of  little  vessels  in  the  submucous 
tissue,  and,  for  the  time  at  least,  interfere  with  the  circulation. 

Congestion  of  the  whole  uterus  is  greatly  relieved  by  removal 
of  weight  from  it  by  abdominal  and  skirt  supporters ;  avoidance 
of  muscular  efforts ;  the  use  of  a  pessary ;  careful  regulation  of 
the  bowels ;  rest,  especially  during  menstruation ;  and  the  use  of 
copious,  warm  vaginal  injections. 

Applications  should  be  made  not  only  by  the  physician,  who  will 
probably  use  the  speculum  not  oftener  than  once  a  week,  but  also 
by  the  patient,  who  should  make  them  daily  by  injections  and 
suppositories.  The  former  should  be  thus  employed :  every  night 
and  morning  a  gallon  of  tepid  or  warm  water,  containing  one  ounce 
of  glycerine  and  one  drachm  of  sulphate  of  zinc,  or  two  of  sulphate 
of  alum,  acetate  of  lead,  or  tannin,  should  be  injected  for  a  period 
varying  from  ten  to  twenty  minutes.  Or  if  it  be  found  necessary 
to  employ  a  stronger  astringent  solution,  a  gallon  of  pure  water 
may  be  used  first,  for  the  time  mentioned,  and  then  a  medicated 
solution,  one  quart  in  amount,  be  used  for  a  short  time  afterwards. 

Vaginal  suppositories  may  likewise  be  made  of  great  service. 
A  suppository  may  be  made  to  contain  three  grains  of  oxide  of 
zinc,  or  of  sulphate  of  alum;   ten  grains  of  mercurial  ointment; 


316  GRANULAR    AND    CYSTIC 

five  grains  of  iodide  of  lead ;  or  two  grains  of  tannin.  To  any  one 
of  these,  should  an  anodyne  be  needed,  one  grain  of  the  extract 
of  belladonna,  or  of  opium,  may  be  added.  These  substances  may 
be  made  into  a  mass  with  powdered  gum  tragacanth,  starch,  or 
slippery  elm,  and  glycerine,  and  the  whole  covered  with  cocoa 
butter.  They  may  be  introduced  by  the  finger,  but  by  the  use  of 
the  vaginal  suppository  tube  elsewhere  mentioned,  there  is  much 
greater  certainty  of  their  coming  in  contact  with  the  diseased  sur- 
face.    Sujopositories  may  be  employed  once  or  twice  a  day. 

Surprise  may  be  felt  at  the  small  amount  of  medicinal  substance 
which  I  propose  to  add  to  each  suppository.  A  great  deal  of  dis- 
comfort often  arises  from  larger  doses  than  I  have  mentioned.  I 
have  repeatedly  seen  patients  for  whom  two  grains  of  tannin  thus 
administered  was  too  large  a  dose,  and  who  had  in  consequence  to 
cut  each  suppository  in  half  before  employing  it. 

Cystic  or  Follicular  Degeneration  of  the  Cervix. 

Definition. — This  form  of  disease,  though  not  so  frequent  as  that 
last  mentioned,  is  by  no  means  rare.  It  consists  in  an  inflammation 
of  mucous  follicles,  which  resemble  those  of  the  cervical  canal,  and 
which  are  scattered  over  the  vaginal  face  of  the  cervix,  and  exist 
even  in  the  cavity  of  the  womb.  "The  cervical  mucous  cysts," 
says  Farre,  "are  lined  by  epithelium  and  basement-membrane. 
They  contain  a  small  quantity  of  mucus  together  with  granule-cells. 
Those  upon  or  near  the  margin  of  the  os  uteri  may  be  sometimes 
observed  to  contain  short  papillae  within  their  margin."  A 
recollection  of  these  facts  is  essential  to  a  full  understanding  of  the 
stages  of  this  form  of  degeneration. 

Pathology. — Follicular  disease  of  the  cervix  shows  three  entirely 
different  phases:  1st.  A  number  of  vesicles,  equal  in  size  to  a  mil- 
let seed  and  filled  with  a  fluid  like  honey,  is  noticed  covering  the 
part..  These  are  due  to  repletion  from  retention  of  the  secretion 
of  the  follicles.  2d.  These  cysts  are  seen  open,  i.  e.,  they  have  burst, 
and  a  depression  marks  the  former  site  of  each.  3d.  The  papillre 
which  they  contain  undergo  hypertrophy  and  cause  the  appearance 
of  red,  elevated,  hemorrhagic-looking  tubercles  in  place  of  the  de- 
pressions just  mentioned.  For  the  thorough  knowledge  of  this 
subject  we  are  indebted,  as  for  so  much  else  relating  to  the  ana- 
tomy and  pathology  of  the  uterus,  to  Dr.  Arthur  Farre.  Usually 
the  cervix  is  seen  studded  over  by  little  globular  bodies  about  as 
large  as  a  hemp  seed  with  here  and  there  a  depression,  and  here  and 


DEGENERATION  OF  THE  CERVIX  UTERI. 


317 


Cystic  degeneration   of 
the  cervix. 


there  a  prominence  of  red  and  irritable  look-  Fig.  85. 

ing  character. 

Synonyyns. — It  will  now  be  readily  appre- 
ciated why  a  variety  of  names  should  have 
been  applied  to  this  disease  when  examined 
at  different  stages.  Follicular  disease  is  sup- 
posed to  be  the  source  of  the  eruptive  aftec- 
tions  described  by  authors  as  acne,  herpes, 
and  aphthfe  of  the  uterus. 

(7«Mse5.— Anything  which  keeps  up  con- 
gestion in  the  cervical  mucous  membrane 
may  give  rise  to  this  affection  of  the  mucous 
glands  of  the  vaginal  cervix.     Among  the  chief  are : 

Cervical  endometritis  ; 
Granular  degeneration ; 
Cervical  hyperplasia. 

Prognosis. — If  a  few  scattered  cysts  appear,  the  prognosis  is 
decidedly  favorable;  but  in  certain  rare  cases,  where  the  whole  of 
the  extremity  of  the  cervix  is  filled  by  them,  nothing  but  ampu- 
tation of  the  part  containing  them  accomplishes  cure. 

Treatment. — The  contents  of  all  the  cysts  should  be  evacuated  by 
a  bistoury,  and  their  cavities  thoroughly  cauterized  by  a  sharp 
point  of  nitrate  of  silver,  chromic  acid,  or  the  acid  nitrate  of  mer- 
cury. Should  the  second  or  third  stage  exist,  the  diseased  surface 
should  be  treated  upon  very  much  the  same  plan  as  that  advised 
for  granular  degeneration. 

Should  a  great  amount  of  cystic  degeneration  exist,  and  cure  not 
follow  evacuation  and  cauterization  of  the  cysts,  the  vaginal  face 
of  the  cervix  should  be  removed  by  the  galvano-caustic  wire,  or  by 
bistoury  or  scissors.  Here,  as  in  cervical  endometritis  of  cystic 
character,  the  rule  of  surgery  which  inculcates  the  ablation  of  a 
part  which  is  the  habitat  of  a  disease  which  proves  incurable  by 
minor  means,  should  be  followed. 


318  SYPHILITIC    ULCER    OF    THE    CERVIX    UTERI. 


CHAPTER    XVIII. 

SYPHILITIC  ULCER  OF  THE  CERVIX  UTERI. 

Frequency. — Syphilis  may  affect  the  cervix  uteri  either  as  a 
primary  or  secondary  disorder,  though  in  neitlier  form  is  it  by  any 
means  common.  It  is  noAV  a  settled  fact  that  true  chancre  may 
locate  itself  upon  the  cervix,  but  not  the  less  certain  is  it  that  it 
rarely  does  so.  I  have  seen  but  one  case  which  I  felt  satisfied  was 
of  this  character.  This  was  proved  by  inoculation,  the  most  certain 
way  in  which  a  strictly  reliable  conclusion  can  be  arrived  at,  and 
by  corroborative  evidence  existing  in  the  presence  of  syphilitic 
roseola  without  primary  disease  elsewhere.  Dr.  Bennet'  states, 
that  in  his  own  practice  it  has  been  very  rarely  met  with,  and 
quotes  in  confirmation  of  his  own  experience  that  of  Ricord,  Cul- 
lerier,  Gibert,  Duparcquc,  and  others.  M.  Bernutz,  who  has  made, 
according  to  Becquerel,-  a  special  study  of  this  subject  in  the  hos- 
pitals of  Paris,  describes  chancres  of  the  os  minutely,  dividing  them 
into  Hunterian,  diphtheritic,  and  ulcerous,  which  resemble  phage- 
denic very  closely.  With  regard  to  secondary  affections  on  the 
cervix,  there  has  been  considerable  discussion,  some  regarding  them 
as  quite  common,  others  as  very  rare.  Becquerel,  after  careful  re- 
search in  rOurcine  Hospital  at  Paris,  was  convinced  of  their  occur- 
rence, and  Bernutz  describes  mucous  patches,  vegetations,  erosions, 
tubercles,  and  gummy  tumors.  I  know  of  no  more  significant 
evidence  of  the  rarity  of  these  affections  upon  the  cervix  than  the 
fact,  that  in  the  most  recent  work  upon  syphilis,  now  before  the 
profession,  a  work  remarkable  for  the  thorough  and  comprehensive 
style  with  which  it  deals  with  all  relating  to  that  subject,  almost 
no  mention  is  made  of  syphilitic  affections  of  the  cervix.  I  allude 
to  the  work  of  Prof.  Bumstead.'  The  author  investigates  the 
character  of  syphilis  when  affecting  all  parts  of  the  body,  even  the 
lachrymal  sacs,  the  membrana  tympani,  etc.,  but  nowhere  is  any 
mention  made  of  the  disease  appearing  on  the  cervix,  except  a 

'  Bennet  on  the  Uterus,  p.  350.  «  Mai.  de  I'Ut^rus,  vol.  i,  p.  169. 

^  Buinstead  on  Venereal  Diseases. 


DIFFERENTIATION.  319 

cursory  statement,  that  at  Bellevue  Hospital  he  had  seen  some 
remarkable  instances  of  mucous  patches  thus  located.  The  sign 
of  the  secondary  disorder  which  we  would  most  naturally  expect 
to  find  in  this  site  would  be  the  mucous  patch,  as  it  is  one  of  the 
most  frequent  of  all  the  manifestations  of  that  stage ;  but  we  are 
informed  by  Messrs.  Davasse  and  Deville,^  that  of  one  hundred 
and  eighty-six  women  aflfected  by  syphilis,  and  examined  in  refer- 
ence to  the  location  of  its  lesions,  they  were  found  on  the  cervix 
uteri  but  once. 

Course  and  Termination. — The  primary  affection  being  located 
on  the  cervix,  the  general  system  becomes  affected  as  from  a 
chancre  on  any  other  part,  and,  as  M.  Gosselin  has  pointed  out, 
instead  of  passing  off  rapidly,  as  it  sometimes  does,  it  may  assume 
the  fungous  type.  During  its  course  the  cervical  chancre  has  a 
marked  tendency  to  become  covered  by  false  membrane,  which 
Robert-  first  noted,  and  Bernutz  subsequently  corroborated.  Un- 
less a  fact  recorded  l)y  Forster^  be  carefully  borne  in  mind  by  the 
diagnostician,  a  grievous  error  may  occur  in  the  differentiation  of 
this  form  of  ulcer  from  malignant  disease.  He  declares  that  syplii- 
litic  ulcers  sometimes  destroy  tissue  so  freely  as  to  penetrate  into 
the  bladder  or  rectum. 

Differentiation.— For  evident  reasons  this  is  a  matter  of  great 
importance,  not  only  as  regards  therapeutics,  but  because  it  may 
involve  a  delicate  legal  question  affecting  the  chastity  of  the 
woman. 

These  are  the  means  of  diagnosis  in  cases  of  chancre : 

Border  of  ulcer  precipitous ; 

Surface  of  ulcer  depressed  ; 

Great  tendency  to  bleed  ; 

Great  tendency  to  false  membranous  covering ; 

Rapid  development  of  constitutional  symptoms ; 

Early  appearance  of  roseola ; 

Transmission  by  inoculation. 

All  of  these  signs  are  of  value,  but  the  only  ones  upon  which  a 
positive  opinion  could  be  based  are  the  last  three. 

Secondary  eruptions,  as,  for  example,  mucous  patches,  vegeta- 
tions, etc.,  which  appear  here  will  be  known  by 

'  Davasse  and  Deville,  Des  Plaques  Muqueuses :  Arch.  G6n.  de  Med.,  1845,  t. 
ix  et  X. 
2  Aran,  Mai.  de  1' Uterus,  p.  524.  »  Klob,  op.  cit.,  p.  243. 


320  DISPLACEMENTS    OF    THE     LTERUS. 

Their  rapid  development ; 
Their  connection  with  constitutional  signs ; 
Simultaneous  affection  of  the  vagina  ; 
Absence  of  chronic  cervical  inflanmiation  : 
The  peculiar  appearance  of  secondary  eruptions. 

Treatment. — This  will  consist  in  cases  of  chancre  of  the  ordi- 
nary treatment  adopted  when  such  an  ulcer  affects  any  other  part. 
In  cases  of  secondary  affections  the  patient  should  be  put  upon  a 
mercurial  course,  the  surface  cauterized,  and  subsequent  dressings 
made  of  mercurial  preparations,  of  which  the  black  or  yellow  wash, 
mercurial  ointment,  and  calomel,  are  the  best. 


CHAPTER    XIX. 

GENERAL  CONSIDERATIONS  UPON  DISPLACEaiEXTS  OF  THE   UTERUS. 

History. — That  the  earliest  practitioners  of  medicine  were  familiar 
with  this  subject  is  abundantly  attested  by  the  writings  of  the 
Greek  and  Koman  schools.  It  is  distinctly  mentioned  by  Hippo- 
crates, and  more  clearly  and  exactly  still  by  Galen  and  Moschion 
about  the  second  century  of  the  Christian  era.  This  remark  applies 
not  only  to  prolapse,  but  also  to  versions,  which  were  evidently- 
understood.  Hippocrates  and  Mosdiion  even  described  latero- 
version,  a  variety  which  has  not  been  much  noticed  by  modern 
writers.  There  is  no  evidence,  however,  that  they  understood  the 
difference  between  versions  and  flexions. 

Passing  over  many  centuries,  at  the  middle  of  the  eighteenth, 
we  find  gynecologists  paying  attention  to  versions,  and  even  to 
flexions,  of  the  pregnant  uterus,  but  losing  sight  of  these  displace- 
ments in  the  non-pregnant  organ.  Versions  w^ere  at  that  period 
described  by  Garthshore,  W.  Hunter,  Jabn,  and  Desgranges ;  and 
flexions  by  Saxtorph,  Wltczek,  Baudelocque,  and  Bcier.  Gartshore 
describes  a  case  of  retroflexion  complicated  by  retroversion,  but  the 
flexion  appears  to  have  made  little  impression  upon  him.  In  1775 
Saxtorph  wrote  an  essay  entitled  "De  Ischuria  ex  utero  retroflexo,'* 
describing  a  case  with  autopsy,  but  the  words  "  orificium  altc  supra 
pubem  reperi,"  show  that  it  was  not  a  true  case.     About  the  same 


DISPLACEMENTS    OF    THE    UTERUS.  321 

time  Wltczek  published  an  unquestionable  case  "  de  utero  retro- 
flexo,"  but  it  occurred  during  utero-gestation,  and  hence  does  not 
concern  our  inquiry.  Both  in  England  and  France  this  subject  of 
displacements  attracted  great  attention  at  this  period.  ^"  At  this 
time  Chopart  upon  his  return  from  England,  where  he  became  well 
acquainted  with  W.  Hunter,  informed  the  Academj^  of  Surgery 
what  progress  was  being  made  in  a  subject  which  had  attracted 
attention  in  France  thirty  years  before." 

Denman  was  the  first  writer  who  described  flexion  of  the  non- 
pregnant uterus,  which  he  did  in  reference  to  a  case  of  retroflexion, 
about  the  year  1800.  The  wanting  link,  the  description  of  anterior 
flexure,  was  not  supplied  until  M.  Ameline,  of  France,  described 
anteflexions  in  1827.  For  our  present  improved  views  upon  the 
subject  we  are  indebted  more  especially  to  the  following  observers: 

Bazin,  Paris 1827. 

Ameline,  Paris 1827. 

Boivin  and  Dugfes,  Paris 1833. 

Simpson,  Edinburgh 1843. 

Amussat,  Paris 1843. 

Bennet,  Edinburgh 1845. 

Hodge,  Philadelphia 18—. 

The  facts  contributed  by  these  authors  have  been  gradually 
merged  into  the  common  stock  of  medical  knowledge,  and  admitted 
into  all  systematic  works  on  gynecology.  I  have  not  of  course 
attempted  to  enumerate  all  writers  upon  displacements,  but  only 
those  who  have  accomplished  some  improvement  or  suggested 
original  views.  Bazin  deserves  the  credit  of  being  one  of  the 
earliest  modern  writers  on  the  subject.  Ameline  not  only  that, 
but  the  additional  merit  of  having  been  the  first  to  fully  describe 
flexions  and  differentiate  them  from  versions.  Boivin  and  Dug^s 
introduced  the  subject  into  a  systematic  work  upon  gynecology, 
and  Amussat  improved  our  knowledge  of  it  as  it  occurs  during  the 
pregnant  state.  But  all  these  results  were  only  foreshadowings  of 
the  eminent  services  of  Simpson,  who  opened  the  way  to  diagnosis 
by  introducing  the  uterine  sound.  At  a  still  later  period  Dr.  Bennet, 
by  insisting  upon  the  fact,  which  Lisfranc  had  stated,  but  failed  to 
impress  upon  gynecologists  out  of  France,  that  structural  disease 
is  very  generally  the  cause  of  displacement,  accomplished  for  the 
subject  scarcely  less  than  his  compatriot. 

In  this  country  the  profession  is  especially  indebted  for  correct 

'  Ousco,  "Thfese  sur  1' Anteflexion  et  la  Retroflexion  de  I'Uterus,"  Paris,  1853. 
21 


322  DISPLACEMENTS    OF    THE    UTEEUS. 

views  upon  the  subject  to  Dewees,  Meigs,  and  Hodge.  More  espe- 
cially has  the  last  of  these  identified  his  name  with  it  by  important 
contributions  to  pathology  and  treatment. 

Pathological  Significance  of  Versions  and  Flexions.— The  ancients 
ascribed  to  these  displacements  many  constitutional  evils,  as 
ftaralysis,  hysteria,  etc.,  and  even  until  a  very  recent  period  they 
were  credited  with  a  great  deal  of  pelvic  pain  and  functional 
uterine  disturbance,  which  it  was  supposed  almost  universally 
attended  them.  Until  1854,  this  belief  prevailed  very  generally, 
having  the  powerful  support  and  endorsement  of  such  men  as 
Velpeau,  Simpson,  and  Valleix.  It  is  true  that  it  was  contested 
by  Cruveilhier  and  Dubois,^  before  the  period  mentioned  ;  but  at 
that  time  a  spirited  discussion  arose  concerning  it  in  the  Academy 
of  Medicine  of  Paris,  which  not  only  threw  much  doubt  upon  it, 
but  gave  rise  to  a  powerful  opposition,  in  the  ranks  of  which  ap- 
peared Depaul,  H.  Bennet,  Aran,  Becquerel,  and  others  equally 
eminent.  They  maintained  that  these  displacements  of  the  womb, 
if  unaccompanied  by  textural  lesion,  produced  no  constitutional 
disturbance,  created,  as  a  rule,  no  discomfort,  and  did  not  deserve 
the  attention  in  treatment  which  had  been  bestowed  upon  them. 
They  did  not  believe  that  the  dislocation  was  the  cause  of  suffer- 
ing when  this  existed  alone,  but  looked  upon  it,  in  such  cases,  as 
an  epiphenomenon  engrafted  upon  some  more  important  lesion. 
Consequently  they  were  opposed  to  reliance  being  placed  upon 
support  by  pessaries  as  one  of  the  essentials  of  treatment,  as  had 
been  done  by  the  other  scliool. 

When  views  supposed  to  be  false  are  repudiated,  those  adopting 
new  ones  are  always  apt  to  run  too  far  into  an  opposite  extreme, 
and  in  this  instance  many  have  done  so.  Scanzoni^  sounds  the 
keynote  of  this  extreme  party  when  he  states  that,  "  flexions  of 
the  womb  do  not  acquire  any  imi)ortance,  nor  are  followed  by  any 
serious  dangers,  save  when  they  are  complicated  with  an  altera- 
tion in  the  texture  of  the  organ." 

The  following  propositions  present  the  views  upon  this  subject 
which  I  think  will  be  found  to  bear  the  test  of  experience : 

1st.  Versions  and  flexions  of  the  womb  may,  but  very  rarely  do, 
exist  without  causing  any  symptoms,  for  in  themselves  they  do 
not  constitute  disease.  Thus  it  is  that  in  rare  cases  we  see  the 
uterus  forced  completely  out  of  its  place  by  tight  clothing,  without 
the  production  of  morbid  signs. 

'  Goupil,  B.  &  G.,  op.  cit,  p.  459.  2  Op  cit.,  Amer.  ed.,  p.  112. 


DEFINITION    AND    SYNONYMS.  323 

2d.  By  interfering  with  escape  of  menstrual  blood,  by  disorder- 
ing uterine  circulation,  and  keeping  up  liypersemia,  by  causing 
pressure  and  friction  from  contact  with  surrounding  parts,  and  by 
creating  a  barrier  to  the  entrance  of  seminal  fluid,  they  become  as 
a  general  rule  of  great  importance  and  require  special  attention. 

3d.  Often  being  the  results,  as  they  are  sometimes  the  causes  of 
uterine  and  periuterine  diseases,  their  treatment  should  be  com- 
bined with  efforts  at  the  alleviation  of  these  states. 

4th.  Treatment  by  pessaries,  combined  with  means  which  re- 
move the  weight  of  the  superincumbent  intestines,  is  of  great 
value.  By  it,  even  although  the  primary  disease  is  not  affected, 
we  may  relieve  one  of  its  most  troublesome  symptoms,  which 
often  reacts  for  evil  in  aggravating  and  prolonging  the  affection 
v^iich  caused  it.  When  the  displacement  has  resulted  from  re- 
laxation of  the  uterine  ligaments,  in  consequence  of  increased 
weight  or  pressure  from  the  abdominal  viscera,  pessaries  prove  a 
most  useful  and  efficient  means  of  treatment.  Even  when  inflam- 
matory action  exists  in  the  endometrium  it  may  become  neces- 
sary to  resort  to  them  to  prevent  resulting  relaxation  of  uterine 
supports. 

5th.  One  reason  for  the  great  prejudice  existing  against  the  use 
of  pessaries  in  the  minds  of  many  is  to  be  found  in  the  fact  that 
most  of  the  enlargements  of  the  uterus  were  attributed  unhesita- 
tingly to  parenchymatous  inflammation.  Mechanically  lifting  an 
inflamed  organ  appeared  repulsive  to  reason.  So  long  as  the  exist- 
ing inflammation  was  uncured,  efforts  appeared  to  be  directed  to  a 
side  issue,  a  result  and  not  the  root  of  the  disorder.  Since  it  is  now 
known  that  what  was  supposed  to  be  chronic  metritis  is  really  a 
vice  of  nutrition  resulting  in  new  formation  of  connective  tissue, 
this  theoretical  objection  falls  to  the  ground. 

6th.  Another  reason  is  this :  it  requires  skill,  and  ingenuity,  the 
result  of  practice,  not  only  to  do  good  with  pessaries,  but  to  apply 
them  without  doing  absolute  harm.  In  the  hands  of  a  physician 
who  has  made  no  special,  or  at  least  careful,  study  of  their  use, 
and  who  habitually  applies  only  a  half-dozen  in  the  course  of  every 
3'ear,  pessaries  are  elements  of  absolute  danger.  It  would  be  as 
unreasonable  to  expect  an  untaught  experimenter  to  fit  the  foot 
comfortably  with  a  shoe,  as  to  hope  for  efficiency,  comfort,  and 
safety  from  a  pessary  applied  by  ignorant  hands. 

Definition  and  Synonyms. — The  term  displacement  is  applied  by 
British  and  American  writers  to  any  decided  removal  of  the  uterus 
from  its  normal  position,  without  reference  to  the   direction   in 


324  DISPLACEMENTS    OF    THE    UTERUS. 

which  it  has  been  moved,  while  French  writers  apply  the  term 
displacement  only  to  ascent  and  descent  of  the  uterus,  reserving 
that  of  deviations  for  versions  and  flexions. 

Anatomy. — The  uterus  is  kept  in  its  normal  relations  in  the 
pelvis  by  the  following  means : 

1st.  By  the  vagina  to  a  limited  extent ; 
2d.  By  the  areolar  tissue  and  fasciae  of  the  pelvis ; 
3d.  By  juxtaposition  with  the  bladder  and  rectum; 
4th.  By  the  folloMdng  ligaments: 

a.  The  round  ligaments,  continuations  of  uterine  tissue ; 

b.  The  utero-vesical  ligaments,  bands  of  pelvic  fascia,  and 

uterine  muscular  tissue  passing  between  the  bladder 
and  the  cervico-corporeal  junction,  where  they  attach 
themselves,  and  prevent  retreat  of  cervix ; 

c.  The  utero-sacral  ligaments,  formed  of  hypogastric  fas- 

cia, and  uterine  and  vaginal  tissue,  extending  from 
posterior  surface  of  cervix,  passing  backwards  to  be 
attached  to  sacrum,  and  preventing  passage  of  cervix 
forwards ; 

d.  The  broad  ligaments,  folds  of  peritoneum,  enclosing 

areolar  tissue,  ovarian   and  round    ligaments,   and 
ovaries;   preventing  lateral,  anterior,  and  posterior 
displacements. 
5th.  By  the  sustaining  influence  of  the  abdominal  cavity. 

None  of  these  means  of  suspension  are  concerned  in  flexions  and 
inversion,  which  are  combated  by  forces  of  entirely  different  nature. 
The  tissue  of  the  unimpregnated  uterus  is  of  such  strong,  resisting 
character  in  the  adult  female,  as  to  prevent  too  great  a  curvature 
of  the  body  upon  the  neck  either  anteriorly,  laterally,  or  posteriorly. 
It  is  to  this  peculiarity  of  structure  that  immunity  from  these 
conditions  is  due. 

"When  stimulated  by  pregnancy,  the  uterine  tissue  develops 
rapidly  into  muscular  structure.  This  keeps  the  cavity  of  the 
organ  closed  by  tonic  contraction,  and  removes  the  possibility  of  in- 
version unless  it  be  accomplished  by  absolute  violence.  But  Avhen 
from  any  cause  this  contractile  power  is  destroyed  and  the  condition 
of  tone  is  rejDlaced  by  one  of  atony,  flexion  or  inversion  may  occur. 

It  is  manifest  that  a  number  of  mechanical  influences  may  force 
an  organ  thus  sustained,  upwards,  downwards,  backwards,  laterally, 
or  even  bend  it  upon  itself  or  turn  it  completely  inside  out,  and 
that  the  direction  of  the  impelling  force,  or  nature  and  position  of 


ANATOMY.  325 

the  loss  of  support  will  determiue  the  character  of  the  displacement. 
The  displacements  which  may  thus  result  have  received  the  fol- 
lowing appellations : 

Ascent ; 

Descent  or  prolapsus ; 
Anteversion ; 
Anteflexion ; 
Retroversion ; 
Retroflexion ; 
Lateroversion ; 
Lateroflexion ; 
Inversion. 

These  varieties  should  not  be  memorized  by  the  student,  for  such 
an  eflJbrt  would  be  uncalled  for.  Let  him  suppose  any  pear-shaped 
bag,  one  of  gutta-percha,  for  instance,  susj^ended  by  j-ielding  sup- 
ports in  a  cavity,  and  it  must  be  evident  that  these,  and  only  these 
changes  of  position  could  be  impressed  upon  it. 

The  general  causes  producing  these  results  upon  the  uterus  are 
the  following: 

1st.  Any  influence  which  increases  the  weight  of  the  uterus; 
2d.  Any  influence  which  enfeebles  the  supports  of  the  uterus ; 
3d.  Any  influence  which  pushes  the  uterus  out  of  place ; 
4th.  Any  influence  which  displaces  the  uterus  by  traction. 

To  state  this  more  fully  in  other  words: 

1st.  The  uterine  supports  are  equal  to  sustaining  the  organ  when 
of  normal  weight ;  but  when  its  weight  is  increased  they  naturally 
fail  in  their  task. 

2d.  Even  if  the  uterus  be  no  heavier  than  it  should  be,  it  may 
become  displaced  from  depreciation  of  that  support  to  which  it  is 
entitled,  and  which  was  made  to  sustain  it. 

3d.  If  both  the  uterus  and  its  sustaining  powers  be  perfectly 
normal,  it  is  evident  that  direct  or  powerful  pressure  may  over- 
come the  latter,  and  force  the  organ  from  its  place. 

4th.  It  is  equally  evident  that  as  by  a  tenaculum  fastened  in  the 
uterus  of  the  cadaver,  we  may  drag  it  from  its  position,  so  may 
contracting  lymph,  or  a  prolapsed  vagina  effect  this  in  a  living 
body. 

All  these  facts  having  been  premised,  a  concise  view  of  the 
special  causes  of  displacements  may  be  thus  presented. 


326  DISPLACEMENTS    OF    THE    UTERUS. 

1.  Influences  increasing  weight  of  uterus. 

Congestion ; 

Tumors  in  the  walls  or  cavity ; 

Pregnancy ; 

Excessive  growth  of  any  of  its  component  parts ; 

Subinvolution ; 

Fluid  retained  in  cavity ; 

Masses  of  cancer  or  tubercle. 

2.  Influences  weakening  uterine  supports. 

Rupture  of  the  perineum ; 
Weakening  of  vaginal  walls; 
Stretching  of  uterine  ligaments; 
"Want  of  tone  in  uterine  tissue; 
Degeneration  of  uterine  tissue ; 
Abnormally  large  pelvis. 

3.  Influences  pressing  the  uterus  out  of  place. 

Tight  clothing; 

Heavy  clothing  supported  on  the  abdomen;" 

Muscular  efforts ; 

Ascites ; 

Abdominal  tumors; 

Abscesses  or  masses  of  lymph ; 

Repletion  of  the  bladder. 

4.  Influences  exerting  traction  on  the  uterus. 

Lymph  deposited  in  pelvic  areolar  tissue; 

Lymph  deposited  on  peritoneum  of  pelvic  viscera; 

Cicatrices  in  vaginal  walls; 

Shortening  of  uterine  ligaments; 

Natural  shortness  of  vagina ; 

Prolapse  of  vagina,  bladder,  or  rectum. 

The  mode  of  action  of  each  of  these  causes  is  so  evident  as  to 
require  no  special  mention  at  this  time,  but  they  will  be  particularly 
alluded  to  hereafter. 

No  circumstance  combines  so  many  of  these  causes  of  disj^lace- 
ment  as  utero-gestation  and  parturition.  Should  involution  follow 
these  without  interruption,  no  tendency  to  displacement  results. 
But  the  process  of  involution  is  frequently  interfered  with.  Then 
as  consequences  of  the  arrest  of  retrograde  metamorphosis  the 
uterus  remains  large  and  heavy ;  the  vagina  voluminous  and  feeble ; 
and  the  uterine  ligaments,  which  owe  their  strength  chiefly  tc  the 
uterine  cortex  which  they  contain,  lax  and  weak.     As  a  result  of 


ASCENT  OF  THE  UTERUS.  327 

parturition,  too,  the  perineum  is  often  enfeebled,  which  allows  of 
prolapse  of  the  vagina,  which  produces  traction  upon  the  uterus. 

This  is  all  that  need  be  said  upon  tlie  subject  of  uterine  dis- 
placements in  general.  I  shall  now  proceed  to  complete  the  outline 
here  sketched,  and  to  go  into  the  details  connected  with  each 
variety  of  the  afiection. 


CHAPTER    XX. 

ASCENT  AND  DESCENT   OP  THE  UTERUS. 

Ascent  of  the  Uterus. 

In  its  normal  condition  the  uterus  descends  into  the  pelvic  cavity 
80  as  to  assume  a  position  about  two  inches  from  the  vulva.  If  its 
weight  be  augmented,  it  comes  much  lower  than  this,  and  continues 
to  do  so  as  its  volume  increases,  until  its  development  becomes  so 
great  that  it  cannot  be  accommodated  by  the  pelvis.  Then  it 
escapes  from  the  cavity  by  ascending  to  a  more  capacious  space 
above  the  superior  strait.  This  change  occurs  in  every  normal 
pregnancy.  During  the  first  three  months  the  uterus  falls  in  the 
pelvis,  being  in  a  state  of  prolapse.  As  the  fourth  month  approaches 
its  volume  becomes  so  great  that  it  can  no  longer  be  retained  in  the 
pelvic  cavity,  and  then  it  escapes  above  the  superior  strait,  where 
sufficient  space  is  aftbrded  for  it  to  undergo  full  development. 
This  is  not  only  so  in  pregnancy ;  the  uterus  is  similarly  afl:ected  by 
morbid  growths.  When,  under  these  circumstances,  it  leaves  the 
pelvis,  the  fact  is  expressed  by  the  term  ascent. 

Ascent  of  the  uterus  is  never  an  original  disease,  but  the  result 
of  some  important  change  connected  with  that  organ,  and  requires 
merely  a  mention.  It  may  occur  whenever  a  tumor  is  developed 
in  connection  with  the  vagina,  rectum,  or  retro-vaginal  cul-de-sac, 
when  there  exists  a  growth  in  the  walls  or  cavity  of  the  uterus 
which  renders  it  too  large  for  accommodation  in  the  pelvis,  or, 
when  an  abdominal  tumor  draws  up  the  uterus.  It  never  requires 
treatment,  and  is  of  importance  only  as  exciting  suspicion  of  preg- 
nancy, or  as  an  evidence  of  morbid  growth  in  some  way  connected 
with  the  organs  of  generation. 


328  PROLAPSUS    UTERI. 

Descent  or  Prolapsus  of  the  Uterus. 

Definition,  Synonyms,  and  Frequency. — The  name  of  this  disorder 
defines  its  character  with  sufficient  clearness.  It  is  of  frequent 
occurrence,  and  under  the  name  of  Falling  of  the  Womb  is  well 
known  to  women,  and  constitutes  for  them  an  object  of  especial 
dread.  As  almost  all  women,  after  the  period  of  fruitfulness  has 
passed,  have  an  intuitive  fear  of  cancer  of  the  uterus,  so  do  a  large 
number  before  that  time  manifest  an  apprehension  of  prolapsus. 
In  the  one  case  the  anxiety  is  for  life,  in  the  other  for  usefulness 
and  comfort. 

Unfortunately  for  the  student  of  this  subject,  its  nomenclature 
has  been  rendered  somewhat  obscure.  By  some,  all  cases  of  pro- 
lapsus in  which  the  uterus  does  not  escape  from  the  vagina,  are 
termed  incomplete,  while  those  in  which  it  does,  are  styled  complete. 
By  others,  complete  j)rotrusion  is  denominated  procidentia ;  and, 
by  others  still,  a  very  slight  descent  without  alteration  of  direction 
of  axis  has  been  designated  by  the  very  odd  name  of  squatting 
uterus.  I  have  striven  to  simplify  the  matter  by  applying  the 
name  prolapsus  to  all,  and  marking  the  degrees  of  descent  by  the 
terms  1st,  2d,  and  3d. 

Anatomy. — The  uterus  is  delicately  poised  in  the  pelvis,  and 
prevented  from  descending  to  its  floor  by  the  following  agencies : 
a  surrounding  investment  of  areolar  tissue,  which  binds  it  to  tlie 
bladder,  the  rectum,  and  the  pelvic  walls ;  certain  ligaments, 
which  attach  it  to  neighboring  points  of  support ;  a  general  sus- 
taining influence  exerted  upon  the  viscera  of  the  abdomen  and 
pelvis  by  the  abdominal  cavity ;  and  the  elastic  walls  of  the  vagina. 
About  the  sustaining  influence  of  the  vagina  there  is  much  doubt, 
some,  like  Savage,  denying  it ;  while  others,  like  Bennet,  West,  and 
Kiwisch,  maintain  it.  My  impression  is,  that  the  tonicity  and 
apposition  of  the  walls  of  this  canal  certainly  effect  something  in 
the  way  of  support,  although  observation  has  led  me  to  modify  very 
much  the  belief  which  I  once  had  in  its  great  influence.  Loss  of 
tone  in  it  resulting  in  prolapsus  vaginse  is  commonly  attended  hy 
a  similar  prolapse  in  the  uterus,  but  it  does  not  follow  that  the 
uterus  falls  from  want  of  support;  it  is  more  probably  dragged 
down  by  the  heavy  vagina. 

On  the  other  hand,  a  good  deal  of  stress  has  been  laid  upon  an 
experiment  for  which  Aran  credits  Stoltz ;  that  of  cutting  the 
vagina  away  without  noting  any  descent  of  the  uterus.  A  "little 
reflection  must  show  that  this  proves  almost  nothing.     It  merely 


VARIETIES.  329 

demonstrates  the  fact  that,  without  the  vagina,  other  supports  are 
sufficient  to  sustain  the  uterus.  No  one  has  ever  maintained  that 
the  vagina  was  the  only  support  which  keeps  the  uterus  up,  nor 
that  others  were  insufficient  without  it. 

A  great  deal  of  support  is  unquestionably  derived  from  the  con- 
nective areolar  tissue,  which  so  closely  unites  the  uterus  with  the 
rectum,  bladder,  and  pelvic  walls,  as  to  involve  displacement  of 
these  viscera  in  its  descent.  Dr.  Savage,  dragging  the  uterus  of  a 
cadaver  forcibly  downwards  by  means  of  a  vulsellum  attached  to 
the  neck,  found  that  after  cutting  its  important  ligaments,  and 
overcoming  by  force  the  action  of  the  vagina,  it  still  would  not 
advance.  "  The  obstruction  was  found  to  be  due  to  the  subperito- 
neal pelvic  cellular  tissue,  particularly  where  it  surrounds  and 
accompanies  the  uterine  bloodvessels." 

The  most  important  factors  in  the  prevention  of  prolapse  are  the 
utero-sacral  ligaments,  which  Aran  considered  the  only  real  ligar 
ments  of  the  uterus.  Arising  from  the  point  of  junction  of  neck 
and  body,  they  usually  embrace  the  rectum  in  their  bifurcation 
posteriorly,  and,  diverging  on  each  side  of  it,  terminate  in  the  sub- 
peritoneal cellular  tissue,  as  high  up  as  the  second  lumbar  vertebra. 
They  are  exceptionally  inserted  into  the  rectum.  It  was  the  recog- 
nition of  this  anatomical  arrangement  of  these  important  ligaments 
which  led  Huguier  to  suggest  that  they  be  called  utero-lumbar, 
instead  of  utero-sacral.  They  consist  of  the  following  elements : 
peritoneum,  pelvic  connective  tissue,  uterine  cortex,  and  vaginal 
muscular  fibre.  Their  influence,  as  likewise  to  a  much  less  degree 
that  of  two  similar  bands  connecting  the  cervix  in  front  with  the 
bladder,  cannot  be  doubted. 

These  are  probably  all  the  factors  which  unite  in  the  prevention 
of  prolapsus  in  the  first  and  second  degrees.   When  they  are  entirely 
overcome  and  the  descent  has  become  complete, 
the  round  and  broad  or  lateral  ligaments  come 
into  action,  but  not  until  that  has  occurred. 

Varieties. — This  displacement  may  occur  very 
suddenly  and  unexpectedly,  or  gradually  and 
l)y  successive  steps.  As  the  symptoms  of  the 
two  varieties  dift'er  only  in  the  rapidity  and 
severity  of  their  development,  and  the  second  is 
much  the  more  frequent,  I  shall  direct  my  re-  Diagrcam  represent- 
marks  chiefly  to  it,  and  describe  the  first  in  a    "'g  the  uterine  axis 

fe^     .  '    .        ^  in  the  three  degrees 

w  words  m  an  appropriate  place.  ^^  prolapsus. 


330  ■       PROLAPSUS    UTERI. 

Prolapsus  may  exist  either  in  the  first,  second,  or  third  degree, 
the  direction  of  the  uterine  axis  in  each  of  which  is  exhibited  in 

Fig.  86. 

In  the  first  the  uterine  axis  is  unaltered,  the  organ  having  merely 
sunk  in  the  pelvis.  In  the  second  the  body  has  gone  towards  the 
sacrum,  the  cervix  having  come  down  to  the  ostium  vaginae.  In 
the  third  the  last  barrier  has  been  overcome,  and  either  a  part  or 
the  whole  of  the  uterus  hangs  between  the  thighs. 

Causes.— The  causes  which  predispose  to  this  accident  are : 

Child  bearing ; 

Laborious  occupations ; 

Advanced  age; 

Habitual  constipation. 
I  know  of  no  way  in  which  I  can  give  so  concise  a  summary  of 
the  exciting  causes  of  prolapsus  as  by  a  reference  to  the  classifica- 
tion to  wliich  I  have  already  referred  under  general  considerations 
upon  displacements ;  for  the  exciting  causes  will  be  found  to  belong 
in  every  case  to  one  of  four  classes:  those  increasing  uterine  weight; 
those  enfeebling  uterine  supports;  those  forcing  the  uterus  down  by 
power  applied  above ;  and  those  drawing  it  down  by  traction  from 
below. 

a.  Examples  of  causes  connected  with  increased  uterine  weight: 

Tumors,  submucous,  subserous,  or  mural ; 
Pregnancy  (rare,  but  sometimes  met  with) ; 
Hypertrophy  or  hyperplasia ; 
Retained  fluid. 

b.  Examples  of  causes  connected  with  enfeeblement  of  uterine 
supports : 

Abnormally  capacious  pelvis; 

Pupture  of  perineum; 

Loss  of  tone  in  vaginal  walls; 

Loss  of  tone  in  uterine  ligaments; 

Absorption  of  fat  from  pelvic  areolar  tissue; 

Laxity  of  abdominal  walls. 

c.  Examples  of  influences  forcing  the  uterus  downwards: 

Violent  coughing; 
Tumors  in  abdomen; 
Ascites ; 

Violent  muscular  eftbrts ; 
Tight  and  heavy  clothing; 
Straining  at  stool. 


CAUSES.  331 

d.  Examples  of  influences  dragging  uterus  down: 
Congenital  or  acquired  shortness  of  vagina; 
Prolapse  of  vagina,  cystocele,  rectocele; 
Subinvolution  of  the  vagina. 

I  have  already  stated  that  these  evil  influences  are  most  com- 
pletely combined  in  the  condition  existing  after  parturition ;  that 
the  uterus  is  heavier  than  normal,  the  recently  distended  vagina 
relaxed  and  feeble,  the  uterine  ligaments  very  much  stretched,  and 
the  sphincteric  muscles  of  the  vagina  often  weakened.  When,  as 
so  often  happens,  rupture  of  the  perineum  and  of  the  cervix  uteri 
occur,  and  are  followed  by  subinvolution  of  vagina,  uterus,  and 
uterine  ligaments,  we  have  in  perfection  all  the  conditions  which 
give  rise  to  this  displacement.  Of  all  the  causes  of  prolapsus  this 
combination  is  the  most  frequent,  and  hence  the  difficulties  attend- 
ing cure.  It  is  for  this  reason  that  prolapse  is  found  to  be  rare  in 
women  who  have  never  borne  children,  less  rare  in  those  wlio  have 
borne  one  only,  and  appears  to  increase  in  frequency  in  proportion 
to  the  frequency  of  the  parturient  process.  Scanzoni  reports  that 
in  114  cases  of  prolapsus  99  occurred  in  women  who  had  borne 
children. 

Next  in  order  of  frequency  will  be  found  to  be  a  condition  which 
occurs  in  old  women,  a  loss  of  vaginal  power  from  atrophy  of  the 
vagina,  and  absorption  of  the  padding  of  fat  which  normally 
occupies  parts  of  the  pelvis,  and  helps  to  aid  that  canal  in  sustaining 
the  uterus.  This  condition  has  been  specially  mentioned  by  some 
of  the  German  pathologists,  and  attention  has  been  called  to  its 
importance  by  Dr.  Barnes,  of  London.  Here,  though  the  uterus 
is  atrophied,  it  descends  in  spite  of  its  lightness,  partly  from  loss 
of  vaginal  support,  and  partly  by  traction  exerted  upon  it  by  the 
prolapsing  vaginal  walls. 

That  the  abdominal  cavity  exerts  upon  the  uterus  a  peculiar 
retentive  power,  no  one  will  question  who  watches  the  influence  of 
respiration  upon  this  organ.  It  rises  and  falls  as  regularly  as  the 
diaphragm  does,  and  behaves  as  if  it  were  itself  directly  concerned 
in  the  respiratory  process.  Dr.  Matthews  Duncan'  has  done  great 
good  by  his  admirable  elucidation  of  this  fact,  and  in  the  future  I 
believe  that  more  valuable  contributions  to  the  etiology  of  uterine 
displacements  will  come  from  investigations  in  that  direction  than 
any  other.  Loss  of  tone  in  the  abdominal  walls  probably  favors 
displacement  by  effecting  an  alteration  of  the  direction  of  force 

'  Researches  in  Obstetrics. 


332  PROLAPSUS    UTERI. 

transmitted  to  the  uterus,  bladder,  and  superior  vaginal  wall,  and 
by  permitting  the  entrance  of  intestines  into  the  anterior  peritoneal 
prolongation  or  anterior  uterine  excavation. 

Increased  uterine  weight  and  pressure  from  above  are  so  plainly 
active  in  creating  prolapsus  that  no  one  will  doubt  their  causative 
influence. 

Pathology. — There  is  no  variety  of  displacement  about  the  patho- 
logy and  mechanism  of  which  gynecologists  are  more  at  variance 
than  this,  and  yet  none  to  which  a  greater  amount  of  honest, 
scientific  labor  has  been  applied  for  the  elucidation  of  these  very 
points.  As  examples,  I  may  cite  the  experimental  researches  of 
Aran,^  Legendre,^  Huguier,^  Savage,^  and  Taylor,^  to  which  the 
seeker  after  more  elaborate  data  is  referred. 

My  limited  space  will  not  permit  me  to  go  fully  into  the  views 
of  these  investigators,  and  I  shall  confine  myself  chiefly  to  a  rather 
dogmatic  statement  of  my  own  opinions,  at  the  same  time  acknowl- 
edging that  they  are,  in  great  extent,  founded  upon  the  investiga- 
tions alluded  to. 

It  matters  not  whether  the  original  cause  of  the  displacement  be 
increase  of  uterine  weight,  depreciation  of  sustaining  power,  or 
direct  force  exerted  upon  the  organ,  an  invariable  result  of  its 
existence  is  diminution  of  the  power  of  the  uterine  supports.  The 
ligaments  are  stretched,  the  vagina  distended  and  doubled  upon 
itself  or  everted,  and  the  contractile  power  of  the  si»hincteric 
muscles  impaired.  The  displaced  organ  is  generally  atiected  by 
congestion  and  inflammation  of  the  mucous  lining,  its  cavity  is 
much  enlarged,  and  solutions  of  continuity  occur  upon  the  cervix. 
The  vaginal  rugpe  are  effaced,  and  the  lining  of  the  canal,  exposed 
to  atmospheric  influences  and  friction,  looks  like  the  cicatrized 
surface  of  scalded  skin  rather  than  mucous  membrane. 

"  The  tension  of  the  aponeurotic  fibres  of  the  broad  ligaments," 
says  Legendre,  "  during  uterine  prolapse,  results  in  compression  of 
the  hypogastric  veins,  as  compression  of  the  veins  of  the  neck  occur, 
from  tension  of  the  cervical  fascia,  when  the  head  is  forcibly  thrown 
backward.  In  this  way,  congestion  of  the  uterus  and  other  pelvic 
organs  is  kept  up."    Prolapsus,  from  its  influence  in  thus  producing 


'  Etudes  Anatomiques  et  Anatomo-pathologique  sur  la  Statique  de  TUterus, 
Paris,  1858,  Archiv.  Gen.  de  Med. 

2  De  la  Chute  de  I'Uterus,  Paris.  1860. 

3  Les  Allongements  Hypertrophiques  du  Col  de  I'Uterus,  Paris,  1859. 
■»  Female  Pelvic  Organs,  London,  2d  ed.,  1870. 

s  On  Amputation  of  the  Cervix  Uteri,  etc.,  New  York,  1869. 


PATHOLOGY.  333 

hyperfemia,  is  usually  attended  by  hyperplasia  of  the  areolar  tissue 
of  the  uterus.  This  organ  undergoes  an  absolute  increase  in  size, 
and  the  tissue  of  the  cervix  is  especially  altered.  Simultaneously 
with  hyperplasia,  there  is  varicose  degeneration  of  the  bloodvessels 
of  the  cervix  and  absorption  of  its  proper  tissue.  This  increases  the 
natural  ductility  of  the  part,  and  upon  any  traction  being  applied  it 
stretches  so  as  to  produce  the  phenomenon  of  variation  in  the  length 
of  the  uterus,  mentioned  under  the  head  of  physical  signs.  The 
walls  of  the  vagina  are  found  much  thickened  by  proliferation  of 
epithelium  and  hypertrophy  of  the  submucous  layers  of  areolar 
tissue.  Thus  it  becomes  not  only  more  capacious,  but  heavier  and 
more  voluminous  than  normal,  and  even  if  its  increase  in  volume 
and  weight  are  consequences  of  uterine  displacement,  it  drags  upon 
the  uterus  and  increases  its  tendency  to  descend. 

The  uterus  may  descend  from  its  normal  place  in  the  pelvis  under 
any  one  of  the  four  influences  which  have  been  mentioned.  It 
must  not,  however,  be  supposed  that  one  only  is  usually  active.  On 
the  contrary,  two,  three,  and  even  four  are  often  combined  in  fur- 
thering the  result.  For  thoroughness  of  study  they  are  examined 
apart,  that  course  being  also  chosen  from  the  fact  that  even  if 
several  causes  are  combined,  one  is  usually  especially  prominent  as 
a  factor. 

If  a  careful  clinical  study  be  made  of  this  interesting  subject,  the 
uterus  will  be  found  to  descend  in  one  of  these  ways: 

1st.  A  woman  who  has  previously  been  in  good  health  begins  to 
complain  of  dragging  about  the  loins,  backache,  and  sense  of  fatigue 
about  the  pelvis.  An  examination  is  made,  and  the  uterus  is  found 
resting  upon  the  floor  of  the  pelvis,  its  axis  unaltered.  There  is  no 
rupture  of  perineum,  no  redundancy  of  vagina,  and  the  habits  of 
life  of  the  patient  preclude  the  possibility  of  muscular  eiforts  or 
tight  clothing  being  agents  in  the  condition.  A  careful  exami- 
nation of  the  displaced  uterus  shows  it  to  be  large  and  heavy 
from  subinvolution,  or  discovers  a  fibrous  tumor  in  its  structure. 
The  natural  supports  have  been  perfect,  but  they  have  been  over- 
taxed and  have  yielded.  Increased  uterine  weight  is  the  prime 
mover  in  the  disorder. 

But  keep  this  case  under  observation.  The  descent  already 
effected  has  drawn  down  the  bladder,  caused  pressure  upon  the  rec- 
tum, established  a  hypersemia  in  the  tissues  of  the  vagina,  and  begun 
already  to  rob  the  uterine  ligaments  of  their  power  by  stretching 
them.  Pressure  on  the  rectum  and  dragging  upon  the  bladder 
create  irritation,  the  patient  "bears  down'    in  evacuating  these 


334  PEOLAPSUS    UTERI. 

viscera,  and  a  new  influence  is  developed :  force  from  above.  Very 
soon  congestion  of  the  vagina  results  in  excessive  areolar  growth, 
this  canal  falls  into  its  own  distended  channel,  and  another  evil 
influence  is  the  result:  traction  upon  the  uterus  from  below.  The 
uterus  has  now  descended  so  that  its  os  projects  between  the  labia 
niajora;  if  its  ligaments  were  stretched  before,  how  much  more  so 
must  they  be  now! 

2d.  A  uterus  is  found  in  the  first  degree  of  prolapsus.  It  is  a 
healthy  uterus,  normal  in  size,  weight,  and  consistency.  Its  sup- 
ports appear  perfect,  and  no  influence  exerts  traction  upon  it  from 
below.  Everything  is  normal,  but  one — the  uterus  has  descended. 
Examination  proves  that  this  woman  has  labored  hard,  lifting 
heavy  weights,  and  placing  herself  in  a  constrained  attitude  to  do 
so;  or  she  has  for  weeks  suft'ered  from  a  spasmodic,  violent  cough ;  or 
from  obstinate  constipation  which  has  caused  tenesmus.  The  cause 
of  the  prolapse  is  evidently  force  applied  to  the  uterus  from  above. 
But  this  remains  the  sole  cause  for  a  short  time  only.  Very  soon 
increased  weight  of  the  uterus  from  congestion,  enfeeblement  of 
uterine  supports  from  prolonged  tension,  and  traction  by  falling 
of  the  hypertrophied  vagina  and  prolapsed  bladder  complete  the 
vicious  circle. 

3d.  An  examination  of  the  uterus  in  a  case  exactly  similar  as  to 
symptoms,  demonstrates  no  increase  of  uterine  M^eight,  no  force 
applied  from  above.  The  woman  is  found  to  have  a  justo-major 
pelvis,  which  has  always  resulted  in  precipitate  labors ;  or  she  is 
past  sixty,  and  a  senile  atrophy  is  developing;  or  the  perineum  is 
ruptured,  and  the  anterior  and  posterior  vaginal  walls  are  protrud- 
ing in  egg-like  pouches  at  the  vulva,  not  suflScicntly  to  drag  upon 
the  uterus,  but  enough  to  shorten  the  vagina  by  allowing  its  distal 
end  to  protrude.  The  mischievous  factor  is  loss  of  uterine  sup- 
port. The  uterus  is  normal  in  weight  and  exposed  to  no  evil  influ- 
ences from  pressure  or  traction,  but  its  feeble  supports  even  then 
are  unfit  for  their  functions,  and  the  uterus  falls.  It  descends  to 
the  second  degree,  and  dragging  upon  the  broad  ligaments,  their 
aponeurotic  expansions  compress  the  hypogastric  veins,  great  con- 
gestion results,  and  at  once  a  new  influence  develops — increased 
uterine  weight.  Now  rectal  and  vesical  tenesmus  and  pressure  by 
the  displaced  abdominal  viscera  add  another  untoward  element — 
force  applied  from  above.  And  as  the  descending  uterus  everts  the 
congested,  voluminous,  and  heavy  vagina,  it  drags  the  oftending 
organ  still  more  rapidly  down. 


PATHOLOGY.  335 

4th.  The  reader  wearied  by  repetition  may  crave  a  respite  here, 
but  he  asks  it  just  where  it  cannot  be  granted,  for  we  come  to  the 
consideration  of  the  most  frequent  and  consequently  most  important 
of  all  the  influences  resulting  in  prolapsus  uteri.  Prolapse  of  the 
uterus  is  sometimes  a  primary  aflection,  but  in  the  great  majority 
of  cases  it  is  secondary,  produced  by  prolapse  of  the  vagina,  which 
literally  drags  it  from  its  position.  There  are  two  methods  in 
which  this  occurs :  1st.  The  perineum  is  ruptured,  and  by  this  the 
vaginal  walls  lose  the  buttress  against  which  they  rest,  and  the 
power  of  the  pubo-coccygeus  muscle  is  diminished.  2d.  A  vagina 
developed  by  utero-gestation  does  not  undergo  involution,  but 
remains  a  large,  voluminous,  and  heavy  bag,  the  redundant  walls 
of  which  overcome  the  resistance  of  the  perineal  body  and  prolapse, 
dragging  the  uterus  down,  either  before  or  simultaneously  w^ith 
their  escape  from  the  vulva. 

Dr.  Duncan,  in  an  essay  read  before  the  Edinburgh  Obstetrical 
Society,^  in  1871,  maintained  that  the  perineum  had  nothing  to  do 
with  the  support  of  the  uterus,  and  that,  therefore,  laceration  of 
this  part  is  not  a  cause  of  prolapsus.  I  do  not  believe  that  the 
perineum  supports  the  uterus  directly,  nor  that  upon  the  cadaver 
its  section  would  result  in  prolapsus,  but  I  believe  that  destruction 
of  the  perineal  body  which  acts  as  a  sphincter  to  the  vagina,  results 
in  loss  of  support  to  both  its  posterior  and  anterior  walls.  These 
prolapse,  their  tissue  becomes  hypertrophied,  and  they  drag  down 
the  bladder  and  then  the  uterus.  Look  at  Fig.  22,  and  see  how 
much  support  vagina  and  bladder  obtain  from  the  perineal  body, 
and  the  results  of  its  rupture  may  be  better  appreciated.  So  long  as 
the  vagina  is  normal  in  volume  and  weight,  and  remains  within  the 
pelvis  with  its  walls  in  apposition,  it  constitutes,  I  think,  a  uterine 
support.  So  soon  as  it  falls  from  the  pelvic  cavity,  becomes  hyper- 
trophied, and  has  its  walls  separated,  it  degenerates  into  a  uterine 
tractor. 

Dr.  Duncan  points  to  the  fact  that  many  cases  of  complete  perineal 
laceration  do  not  produce  prolapsus  uteri.  This  is  true.  Such 
laceration  is  usually  the  result  of  parturition,  and  is,  I  am  patisfierl, 
often  a  cause  of  subinvolution  of  the  vagina.  If  this  condition  has 
resulted,  the  laceration  is  very  generally  followed  by  prolapsus 
vaginae,  and  thus  by  descent  of  the  uterus.  If  vaginal  involution 
have  not  been  interfered  with,  it  is  usually  not  so. 

'  Transactions,  vol.  ii,  p.  269. 


336  PEOLAPSUS    UTERI. 

Aran  points  out  the  fact,  that  removal  of  the  vagina  from  the 
cadaver  does  not  produce  uterine  prolapse,  and  Dr.  Duncan  declares, 
"I  have  no  doubt  that  if,  by  way  of  experiment,  the  perineum  was 
cut  through  in  a  healthy  woman,  no  tendency  to  prolapsus  would 
be  thereby  produced."  I  freely  accept  both  experiment  and  propo- 
sition, but  I  cannot  agree  in  the  deductions  based  upon  them. 
When  the  uterine  ligaments  are  strong,  the  uterus  does  not  readily 
leave  its  position.  Sometimes  traction  steadily  exerted  upon  the 
cervix  fails  to  draw  down  the  body,  but  stretches  the  neck  so  that 
the  uterus  measures  by  the  sound  between  six  and  seven  inches. 
Klob^  declares,  that  "  relaxation  of  the  uterine  tissue  is  noticeable 
in  the  region  of  the  external  orifice,  and  consequently  in  what  was 
previously  the  vaginal  portion  and  lower  segment  of  the  cervix, 
which  part  often  assumes  a  spongy  softness.  This  relaxation  must 
be  attributed  to  the  varicose  condition  of  the  bloodvessels,  and 
absorption  of  the  cervical  tissue."  This,  and  not  hypertrophy,  is 
probably  the  condition  of  this  distended  part.  In  many  cases, 
before  prolapse  occurs,  the  uterus  is  affected  by  areolar  hyper- 
plasia, or  the  local  atrophic  state  engendered  by  flexion,  which  last 
Dr.  Hewitt  regards  as  a  frequent  source  of  it,  and  when  thus  weak- 
ened it  readily  yields  to  traction.  When  the  tractile  force  is 
checked  by  reposition  of  the  uterus,  the  neck  instantly  contracts, 
and  the  length  of  the  whole  organ  greatly  diminishes. 

May  this  fact  not  explain  the  experience  of  Huguier,  "\^'llO  found 
only  two  cases  of  true  prolapse  in  sixty  reported  cases,  and  of  Routh, 
who  in  a  large  experience  met  with  only  three?  It  seems  to  me 
highly  probable  that  these  investigators,  making  their  measure- 
ments while  the  uterus  was  prolapsed  to  the  third  degree,  concluded 
that  hypertrophic  elongation  of  the  supra-vaginal  portion  existed, 
when  in  reality  this  peculiarly  elastic  tissue,  which  was  the  conse- 
quence and  not  the  cause  of  the  descent,  was  the  true  pathological 
condition.  Certainly  some  such  explanation  must  account  for  the 
remarkable  discrepancy  which  exists  between  tjie  results  of  these 
two  eminent  gynecologists  and  the  great  majority,  whose  experience 
is  opposed  to  theirs. 

In  these  cases  the  force  of  traction  appears  to  expend  itself  upon 
the  most  powerful  uterine  ligaments,  those  inserted  at  the  axis  of 
rotation,  the  cervico-corporeal  junction.  They  yield,  and  the  cervix 
advances  towards  the  vulva,  but  the  uterus,  supported  though  it 
is  by  factors  of  less  power,  resists  steady  traction,  and  remains  in 

•  Op.  cit.,  p.  88. 


PATHOLOGY.  337 

place.  Legenclre  attaclied  to  the  cervix  uteri  of  a  cadaver,  a 
weight  of  iifteen  kilogrammes,  which  was  gradually  increased  to 
lifty  during  the  period  of  an  hour,  then  diminished  to  thirty,  and 
kept  at  that  for  two  hours.  At  the  commencement  of  the  experi- 
ment, the  uterine  canal  measured  by  the  sound  five  centimetres, 
and  at  its  conclusion  nine,  the  lengthening  being  chiefly  in  the 
cervix.  In  other  experiments,  a  less  weight  kept  in  action  for 
several  days,  caused  complete  prolapse  with  elongation  of  the  cervix 
uteri. 

Since  the  appearance  of  Huguier's  essay  upon  supra  and  infra- 
vaginal  elongation  of  the  cervix  as  conditions  commonly  mistaken 
for  prolapsus,  writers  have  commonly  considered  hypertrophic 
elongation  of  the  cervix  below  the  vaginal  junction  under  this 
head.  I  shall  not  do  so,  because  the  propriety  of  such  a  course 
seems  to  me  to  be  sustained  neither  by  clinical  observation  noi 
pathological  investigation,  and  because  true  cervical  liypertrophy 
will  be  elsewhere  treated  of. 

That  there  is  a  form  of  hypertrophic  elongation  of  the  cervix 
uteri,  which  occurs  below  the  cervico-vaginal  junction,  and  appears 
upon  very  superficial  examination  to  resemble  prolapsus,  or  even 
produces  that  condition  by  traction,  I,  of  course,  admit.  But  it 
appears  to  me  erroneous  to  regard  supra-vaginal  elongation,  which 
is  marked  by  an  attenuation  of  the  tissues  of  the  neck  and  "  a 
spongy  softness,"  according  to  Klob  attributable  to  a  "  varicose 
condition  of  the  bloodvessels  and  absorption  of  the  cervical  tissues," 
as  true  hypertrophy. 

It  is  highly  probable  that  this  condition,  the  result  of  traction, 
may  occur  during  pregnancy,  and  exist  as  a  source  of  great  annoy- 
ance after  it.  The  following  deductions  by  M.  Gueniot^  sub- 
stantiate this  view : 

"1.  In  certain  women  there  exists  during  pregnancy,  and  occa- 
sionally at  the  time  of  parturition,  a  special  afi:ection  of  the  neck 
of  the  womb,  which  generally  passes  unrecognized,  and  has  not 
hitherto  been  the  subject  of  any  description. 

"  2.  This  aflection  may  be  designated  under  the  name  of  (Edema- 
tous Elorigation  with  Prolapse  of  the  Neck^  which  indicates  the  prin- 
cipal constituent  traits.  Hyperemia  and  turgescence  of  the  organ, 
the  arrangement  of  its  cavity,  which  is  transformed  into  a  long 
and  freely  patent  canal ;  the  rapidit}^  with  which  these  symptoms 
may  disappear,  and  the  great  facility  with  which  they  may  be 


'  Archives  Gen.  de  Med.,  Juillet,  1872. 

22 


338  PROLAPSUS    UTERI. 

reproduced  under  certain  circumstances,  are  all  so  many  funda- 
mental characters  of  the  affection.  Ulceration  of  the  os  tincse, 
occlusion  of  the  vagina,  a  thin  and  flaccid  condition  of  the  uterine 
walls,  are  also  almost  constant  symptoms ;  as  are  also  circumpelvic 
pains,  a  feeling  of  general  dehility,  and  variable  disturbances  in 
micturition. 

"  3.  The  causes  of  this  change  in  the  neck  of  the  uterus  are 
complex ;  they  are  derived  from  two  sources :  certain  anatomical 
dispositions  of  the  organ,  and  various  circumstances  exerting  upon 
it  a  prolonged  mechanical  action. 

"4.  Although  very  rare,  oedematous  elongation  with  prolapse 
of  the  neck  is,  without  doubt,  a  less  exceptional  affection  than  one 
would  be  inclined  to  imagine.  Many  observers  have  erroneously 
assimilated  it  to  hypertrophic  elongation,  or  to  simple  prolapsus, 
to  which  affections,  in  truth,  it  presents  a  great  analogy,  but  from 
which  it  is  essentially  distinguished  by  proper  and  very  important 
characters," 

Coarse^  Duration^  and  Termination. — Prolapsus  uteri  is  unlimited 
in  its  duration,  and,  unless  relieved  by  art,  will  continue  indefi- 
nitely. It  impairs  the  patient's  comfort  and  capacity  for  exertion, 
but  rarely  has  a  fatal  termination,  unless  by  exciting  peritoneal 
inflammation,  or  pelvic  cellulitis,  as  I  have  seen  it  do  in  several 
cases.  Even  in  the  chronic  form  of  the  disease,  death  lias  in  very 
rare  cases  occurred  from  urinsemia,  the  result  of  interference  with 
the  ureters.  The  trigone  of  the  bladder  becoming  displaced  to 
such  an  extent  that  the  orifices  of  the  ureters  are  pressed  firmly 
against  the  sympliysis  i:)ubis  by  the  mass  behind  it,  they  become 
obstructed  and  distended,  and  in  time  hydronephrosis  may  result. 
Virchow'  and  Kiwisch^  both  announce  this  fact.  An  interesting 
instance  of  death  thus  produced  may  be  found  in  the  twelfth 
volume  of  the  Transactions  of  the  London  Obstetrical  Society, 
reported  by  Dr.  Phillips,  A  case  of  fatal  irreducible  prolapse, 
recorded  by  Dr.  Alexander  Munro,  is  referred  to  on  page  343  of 
this  work.  In  a  case  of  incarcerated  uterus  occurring  in  my  own 
experience,  and  which  Avill  receive  further  mention  elsewhere  in 
this  article,  I  was  compelled  to  resort  to  a  degree  of  force  in  return- 
ing the  displaced  organ,  which  at  the  time  of  application  I  regarded 
as  attended  by  extreme  danger.  Had  my  efforts  not  succeeded, 
death  would,  I  feel  sure,  have  resulted ;  for  the  uterus  and  sur- 
rounding parts  appeared  to  be  about  passing  into  a  state  of  gan- 


'  Trans.  Obstet.  Soc.  of  Berlin,  1847.  *  Clinical  Lectures. 


SYMPTOMS  —  PHYSICAL    SIGNS.  339 

grene.  This  case  before  I  saw  it  had  resisted  all  the  efforts  which 
were  applied  by  three  competent  physicians.  After  forcible  replace- 
ment, tlie  entire  lining  membrane  of  the  vagina  sloughed,  and  the 
patient  narrowly  escaped  death  from  peritonitis,  which  was  excited 
and  ran  a  violent  course.  Forcible  taxis  was  resorted  to,  with  a 
conviction  on  the  part  of  the  attending  physicians  and  myself,  that 
the  issue  involved  either  restitution  of  the  uterus  or  death. 

Symptoms. — The  symptoms  of  prolapsus  are  dependent  upon 
two  results  growing  out  of  the  displacement :  the  mechanical  in- 
terference of  the  womb  with  surrounding  parts,  and  alteration 
induced  in  its  circulation  and  tissue  by  reason  of  its  abnormal 
position.  The  uterus  may  remain  even  in  the  third  degree  of 
descent  without  any  marked  symptoms,  but  generally  congestion, 
areolar  hyperplasia,  and  granular  degeneration  occur,  which  render 
it  sensitive  and  intolerant  of  pressure  or  friction.  At  the  same 
time,  by  dragging  upon  the  bladder,  rectuui,  and  all  the  pelvic 
areolar  tissue  and  fasciee,  and  by  protruding  between  the  labia,  it 
produces  discomfort  and  often  impedes  locomotion  to  a  great  ex- 
tent. The  most  prominent  of  the  symptoms  thus  created  are  the 
following : 

Sensation  of  dragging  and  weight  in  the  pelvis ; 

Rectal  and  vesical  irritation  ; 

Pain  in  back  and  loins ; 

Great  fatigue  from  walking ; 

Inability  to  lift  weights  ; 

Leucorrhoea  and  other  sio-ns  of  cong-estion. 

It  is  a  very  singular  and  striking  fact,  that  in  prolapsus,  even  of 
the  third  degree,  there  is  very  commonly  no  menstrual  disorder, 
and  equally  remarkable  that  sterility  does  not  ordinarily  exist. 
These  immunities  are  probably  dependent  upon  the  facts  that  the 
uterine  catarrh  which  usually  exists  is  rather  the  result  of  a  passive 
congestion  of  the  endometrium  than  of  true  inflammation,  and 
that  the  axis  of  the  organ,  although  altered  in  direction,  is  not  bent 
upon  itself  so  that  an  obstruction  in  it  is  created. 

Physical  Signs. — All  the  symptoms  detailed  will  only  excite  sus- 
picion and  prompt  an  examination  which  will  fully  elucidate  the 
case.  Should  the  affection  exist  only  in  the  first  degree,  tlie  finger 
passed  up  the  vagina  will  meet  with  the  os  low  down  in  the  pelvis 
and  pressing  upon  its  floor.  As  it  is  slid  upward  in  front  of  the 
cervix  and  along  the  base  of  the  bladder,  the  resisting  anterior 


340  PROLAPSUS    UTEEI. 

wall  of  the  uterus  will  be  clearly  distinguished,  and  it   may  be 
found  that  anteversion  or  anteflexion  exists,  complicating  prolapsus. 

If  the  second  degree  have  been  reached,  the  os  will  be  found  at 
the  ostium  vaginae,  prevented  from  escaping  only  by  the  resistance 
of  the  sphincteric  muscles,  and  the  body,  instead  of  lying  forwards, 
will  be  to  some  extent  retroverted.  To  determine  the  degree  of 
prolapsus,  more  especially  in  tins  stage,  the  patient  should  be 
examined  standing. 

Si^'ht  and  touch  will  combine  in  making  a  diagnosis  in  the  third 
degree  of  prolapse  rapid  and  easy,  but  even  here  I  have  known 
very  grievous  mistakes  committed.  The  apparent  ease  of  the  diag- 
nosis sometimes  causes  error  by  inducing  neglect  of  that  caution 
and  watchfulness  which,  even  in  the  simplest  cases  of  disease,  con- 
stitute the  only  safeguard  of  the  i)h3'sician. 

One  very  curious  phenomenon  which  in  the  physical  investigation 
of  these  cases  must  have  struck  every  practitioner  is  this:  the 
uterus  being  procident  and  a  sound  introduced,  it  passes  up  for  the 
distance  of  five  or  six  inches.  The  organ  now  being  replaced,  and 
again  examined  by  the  sound,  it  is  found  to  measure  only  three  or 
four,  and  this  experiment  may  be  repeated  any  number  of  times 
with  the  same  result.  The  explanation  of  this  fact  is  given  in 
connection  with  the  subject  of  pathology. 

Differentiation. — In  any  of  its  varieties  prolapsus  uteri  may  be 
confounded  with  fibrous  polypus,  inversion  of  the  uterus,  and 
hypertrophic  elongation  of  the  neck,  from  all  of  which,  however, 
it  is  readily  distinguished  if  the  practitioner  be  awake  to  the  possi- 
bility of  error.  From  the  first  it  is  known  by  the  presence  of  the 
OS  and  cervix,  and  the  general  shape  of  the  mass.  From  the  second, 
by  the  presence  of  the  os  and  cervix,  and  absence  of  the  signs  of 
inversion.  The  third  will  readily  be  recognized  by  the  great  length 
of  the  cervix,  the  impossibility  of  replacing  the  supposed  prolapsed 
organ,  and  the  great  depth  of  the  uterus  discovered  by  the  uterine 
probe,  after  it  has  been  restored  to  the  pelvis. 

Prognosis. — The  prognosis  as  to  cure  is  \QTy  bad,  and  even  as  to 
complete  relief  not  good.  It  will  depend  somewhat  upon  the  state 
of  the  uterus  and  vagina.  Should  the  former  be  much  enlarged  from 
a  fibrous  tumor,  or  other  disorder  little  amenable  to  treatment,  no 
amount  of  support  will  prove  suflicicnt  to  sustain  it.  On  the  other 
hand,  even  if  the  uterus  be  nearly  normal  in  Aveight  and  volume, 
the  prospect  of  supporting  it  will  be  sliglit  if  the  vaginal  walls  be 
greatly   distended   and  have   undergone   much    atrophy,  for  the 


COMPLICATIONS.  341 

vagina  is  the  only  natural  uterine  support  which  we  can  enlist  by 
surgical  means. 

Complications. — Prolapsus  of  the  uterus  in  its  first  and  second 
degrees,  and  still  more  frequently  in  its  third,  produces  the  follow- 
ing complications: 

Congestion  of  the  uterus  and  its  appendages; 

Endometritis  and  Fallopian  salpingitis; 

Hyperplasia  of  uterus; 

Hypertrophic  elongation  of  the  cervix; 

Cystocele ; 

Rectocele. 

As  soon  as  the  uterus  descends  into  complete  prolapse,  and  to  a 
less  extent  when  it  has  reached  only  the  first  and  second  degrees, 
its  tissue  becomes  congested,  and  appears  swollen,  cedematous,  soft, 
and  relaxed.  In  time  this  passive  hyi^eraemia  induces  hyperplasia, 
which  especially  affects  the  connective  tissue.  As  a  consequence 
the  uterus  is  enlarged,  and  increased  in  weight  and  capacity.  Not 
only  do  congestion  and  hyperplasia  affect  the  parenchyma  of  the 
uterus ;  the  mucous  membrane  and  submucous  tissue  are  likewise 
disordered,  and  endometritis  is  an  invariable  consequence  of  jiro- 
lapse.  It  has  been  already  stated  that  peculiar  changes  occur  in  the 
cervix.  This  part  becomes  particularly  soft  and  relaxed ;  its  ves- 
sels become  varicose,  and  the  muscular  tissue  is  often  absorbed  in 
great  degree. 

In  consequence  of  these  secondary  morbid  states  we  generally 
have  as  concomitant  symptoms,  leucorrhcea,  dilatation  and  eversion 
of  the  cervix,  disorders  of  the  bladder  and  rectum,  and  sometimes 
cystitis.  Eversion  of  the  cervix  is  too  important  a  feature  of  the 
condition  to  be  passed  by  without  special  mention.  As  the  uterus 
descends  it  inverts  the  vagina.  This,  by  its  cervical  attachment, 
which  now  becomes  depressed  to  a  point  far  below  its  upper  portion, 
makes  constant  traction  upon  the  os  externum ;  the  principle  being 
the  same  as  that  by  which  the  coljieurynter  is  made  to  dilate  this 
part  for  the  establishing  or  expediting  the  first  stage  of  labor.  As 
this  action  is  prolonged  and  increased  by  further  descent  of  the 
uterus  and  inversion  of  the  vagina,  the  cervical  canal  is  rolled  out, 
so  as  to  become  completely  everted,  and  the  os  internum  becomes 
literally  the  external  and  only  os  uteri,  the  real  os  externum  having 
disappeared  by  expansion. 

Dislocation  of  the  bladder  is  accomplished  by  uterine  descent  to 
such  an  extent  that  if  a  catlieter  be  introduced  it  will  pass  down- 


342  PROLAPSUS    UTERI. 

wards  and  backwards.  This  complication  is  important,  for  not 
only  do  traction  and  dislocation  tend  to  the  production  of  cystitis ; 
it  is  further  induced  by  reflex  irritation  and  by  decomposition  of 
urine  occurring  from  retention,  after  urination,  in  the  pocket 
formed  by  the  inverted  wall  of  the  bladder.  By  a  similar  process 
prolapse  of  the  anterior  wall  of  the  rectum  occurs,  and  results  in 
fecal  impaction  at  this  point. 

Sadden  or  Acute  Prolapsus  may  come  on  from  any  great  eftbrt,  a 
fall,  or  violent  contraction  of  the  abdominal  muscles,  acting  upon 
a  uterus  which  is  enlarged  by  hyperplasia,  subinvolution,  preg- 
nancy, or  tumors.  It  may  even  occur  to  a  uterus  normal  in  size 
and  constituency.  In  an  instant  the  patient  feels  that  something 
has  given  way  within  her,  becomes  prostrate  and  much  alarmed, 
and  suffers  pain  of  an  expulsive  character,  as  if  desirous  of  forcing 
something  from  the  pelvis.  I  have  twice  seen  it  occur  within  a 
fortnight  after  delivery  from  sudden  and  violent  muscular  effort: 
and  once  in  a  nulliparous  girl  of  nineteen  years,  in  consequence  of 
a  violent  muscular  effort  made  to  lift  a  heavy  weight,  the  cervix 
was  driven  out  of  the  vulva,  the  body  being  arrested  by  the  sphinc- 
ter vaginse  and  perineal  septum.  The  last  patient  I  saw  a  year  after 
the  accident.  She  had  suffered  intensely  from  the  disi)laccment,  but 
from  false  modesty  had  never  told  of  it.  I  discovered  distinct  traces 
of  the  hymen,  which  I  had  every  reason,  both  physical  and  moral, 
to  believe  had  not  been  ruptured  by  sexual  congress. 

In  such  a  case  as  tliis  it  appears  to  me  highly  probable  that  the 
utero-sacral  ligaments  are  ruptured.  This  supposition,  the  difficulty 
of  proving  which  by  necropsy  is  apparent,  may  have  attracted 
attention,  but  the  only  allusion  to  it  which  I  have  met  with  is  the 
following  from  Courty,  who,  in  speaking  of  the  utero-sacral  liga- 
ments says,  "if  they  are  stretched  or  torn  the  entire  organ  falls." 

In  acute  prolapsus,  should  reduction  not  be  effected  at  once, 
violent  pain  will  be  felt  over  the  sacrum  and  groins,  and  the  degree 
of  traction  exerted  upon  the  pelvic  peritoneum  may  result  in  dan- 
gerous inflammation. 

Treatment.— The  first  indication  as  to  treatment  is  to  return  the 
displaced  organ  to  its  normal  position ;  the  second,  to  keep  it  there. 

Methods  of  Replacing  the  Uterus.— In  general  no  difliculty  will 
attend  the  performance  of  the  first  indication,  but  in  some  cases 
careful  and  intelligent  taxis  will  be  necessary.  The  best  method 
for  applying  this  is  the  following:  the  patient,  after  tborough 
evacuation  of  the  bladder  and  rectum,  if  this  be  possible,  should 
be  placed  upon  her  knees  and  chest,  in  order  to  cause  gravitation 


METHODS    OF    SUSTAINING    THE    UTERUS.  343 

of  the  pelvic  and  abdominal  viscera  towards  the  diaphragm.  She 
should  not  kneel  upon  a  soft  or  yielding  bed,  into  which  the 
knees  would  sink,  but  upon  the  floor  or  a  table,  for  the  object  of 
the  posture  is  to  elevate  the  buttocks,  and  depress  the  thorax  as 
much  as  possible.  Ten  or  fifteen  minutes  should  then  be  allowed 
to  elapse  before  any  eftbrts  are  made  at  reduction.  In  this  time 
the  intense  congestion  which  exists  in  the  pelvic  viscera  will  greatly 
diminish.  The  operator  then  taking  the  cervix  into  the  grasp  of 
his  index,  middle,  and  ring  fingers,  pushes  the  uterus  firmly  and 
forcibly  upwards  in  coincidence  with  the  axis  of  the  inferior  strait. 
Wliile  the  right  hand  is  thus  employed,  the  left  rests  upon  the  back 
of  the  patient  and  steadies  her  body.  !No  sudden  or  violent  force 
is  exerted,  but  by  steady  pressure,  kept  up,  if  necessary,  for  fifteen, 
twenty,  or  thirty  minutes,  the  uterus  is  restored  to  its  place. 

Few  cases  will  resist  this  kind  of  effort  at  reduction,  although 
some  may  do  so.  For  example.  Dr.  Alexander  Monro  has  recorded 
a  case  in  which  prolapsus  occurred  in  a  child  three  3'ears  of  age, 
which  proved  irreducible,  and  resulted  in  death.  I  have  already 
referred  to  a  case  in  which  an  incarcerated  uterus,  which  appeared 
upon  the  point  of  becoming  gangrenous,  could  not  be  reduced  by 
the  method  described.  As  no  time  was  to  be  lost,  I  produced 
complete  ansesthesia,  and  then  taking  the  organ  firmly  in  the 
extremities  of  the  thumb  and  three  fingers,  I  carried  it  by  main 
force  into  position. 

Methods  of  Sustaining  the  Uterus. — Before  pursuing  any  special 
course  of  treatment  for  this  end,  the  practitioner  should  endeavor 
to  discover  the  cause  of  the  descent.  If  it  be  due  to  increase  in 
the  weight  of  the  uterus,  or  to  ^^ressure  exerted  upon  it  from 
above,  it  is  evident  that  the  indication  will  be  very  diflerent  from 
what  it  would  be  if  the  cause  were  traction  by  a  prolapsed  vagina. 
Unfortunately,  however,  after  the  disease  has  existed  for  some 
time,  it  is  often  impossible  to  fix  definitely  upon  the  cause ;  for  even 
if  it  were  originally  increase  of  uterine  weight,  the  long  inversion 
of  the  vagina,  and  stretching  of  the  uterine  ligaments  involved  in 
its  descent,  w411  have  destroyed  all  power  in  these  jmrts. 

As  far  as  possible,  however,  the  original  cause  should  be  ascer- 
tained, and  if  it  be  properly  sought  for  it  will,  in  a  number  of 
cases,  be  discovered.  For  example,  suppose  that  there  is  no  en- 
largement or  prolapse  of  the  vagina,  no  evidence  of  excessive  down- 
ward pressure,  and  yet  the  uterus  lies  upon  the  pelvic  floor. 
Strength  should  be  given  to  its  normal  supports. 

Suppose,  on  the  other  hand,  that  the  vagina  be  found  to  be  in 


344  PROLAPSUS    UTERI. 

its  normal  state,  and  the  prolapsed  uterus  very  heavy,  weighing,  per- 
haps, three  times  what  it  should.  This  increase  of  weight  should 
receive  especial  attention. 

If,  again,  the  insignificant,  atrophied  uterus  of  an  old  woman  of 
seventy  be  prolapsed  into  a  large,  flabby,  non-contractile  vagina, 
traction  by  this  vagina  may  safely  be  credited  with  the  uterine 
displacement. 

Lastly,  if  the  common  coincidence  of  rupture  of  the  perineum, 
with  subinvolution,  and  prolapse  of  the  vagina  and  uterus  be  en- 
countered, it  may  be  assumed  that  increase  of  uterine  weight,  loss 
of  support,  and  traction,  have  combined  to  bring  about  the  issue. 

It  should  be  the  care  of  the  physician  to  keep  every  one  of  these 
indications  in  mind  ;  and  in  every  case  attend  first  to  that,  which 
concerns  the  primary  and  most  important  factor ;  second,  to  those 
which  are  secondary  and  created  by  the  displacement  itself. 

The  means  adapted  to  prevention  of  pressure  from  above  are: 

Removing  weight  of  clothing  by  use  of  skirt-supporters  ; 
Removing  weight  of  intestines  by  prohibition  of  tight  clothing, 
use  of  an  al)dominal  supporter,  and  avoidance  of  eftbrt ; 
Prevontino-  accumulation  of  urine  and  feces. 

The  skirt-supporter  is  merely  a  pair  of  suspenders  that  may  be 
contrived  by  any  woman  of  ordinary  ingenuity,  and  which  enables 
the  patient  to  carry  the  whole  weight  of  the  under-garments  upon 
the  shoulders.  A  representation  of  a  very  good  one  will  be  found 
on  page  301. 

There  are  many  varieties  of  the  abdominal  supporter,  some  of 
which,  unfortunately,  are  so  constructed  as  to  do  absolute  harm. 
Should  compression  be  exerted  by  them  upon  the  abdomen  above 
the  navel,  it  will  tend  to  increase  pressure  upon  the  uterus,  or  at 
least  to  annul  all  the  benefit  of  that  exerted  below  this  point. 
The  principle  upon  which  these  supporters  should  act  is  this — the^^ 
should  do  just  what  the  patient's  hands  do  when  she  places  them 
above  tlie  pubes,  and  lifts  the  abdominal  viscera.  Some  of  them 
are  composed  simply  of  bands  of  thick  cloth,  others  are  pads  or 
disks  of  horn  or  metal,  with  encircling  bands  like  those  of  the 
hernial  truss.  The  physician  may  choose  intelligently,  if  he  only 
bears  in  mind  what  it  is  that  he  desires  to  accomplish  by  them. 

During  the  continuance  of  treatment  the  patient  should  be  limited 
as  to  exercise  and  confined  to  bed  during  menstrual  epochs,  when 
the  uterus  is  known  to  be  heavier  than  at  other  times.  Should 
the  accident  have  immediately  followed  parturition,  she  should  be 


ASTRINGENTS    AND    TONICS.  345 

kept  in  the  recumbent  posture  to  favor  the  accomplishment  of 
involution. 

Means  adapted  to  diminution  of  uterine  weight  are: 

Removing  polypi,  tumors,  etc.,  bj  operation ; 
Removing  uterine   inflammation,  hypertrophy,  and  congestion, 
by  appropriate  treatment ; 

Amputation  of  the  neck  of  the  womb. 

Sometimes,  by  applying  appropriate  treatment  to  an  enlarged 
cervix,  the  uterus  is  in  time  so  much  lightened  by  cure  of  attendant 
hypersemia  that  relief  is  eflected,  but  in  other  cases  the  hypersemia 
is  so  persistent  and  rebellious  that  these  means  fail,  and  resort  has 
been  had  to  amputation  of  the  neck.  M.  Iluguier,  of  Paris,  was, 
in  1848,  the  first  to  perform  this  operation  for  prolapsus,  though  it 
had  long  been  resorted  to  for  cancer.  Since  that  time  it  has  been 
performed  by  many  others,  after  methods  which  will  be  described 
in  a  chapter  devoted  to  the  operation.  It  must  not  be  supposed 
that  the  mere  removal  of  superabundant  tissue  is  relied  upon  for 
the  diminution  of  uterine  weight.  It  is  rather  the  derivative  and 
alterative  influences  set  up  by  amputation  of  which  the  surgeon 

deavors  to  avail  himself. 

Means  for  strengthening  or  supplementing  uterine  supports: 

The  recumbent  posture ; 
Local  astringents  and  tonics  ; 
General  tonics ; 
Pessaries. 

The  recumbent  posture^  persistently  persevered  in,  accomplishes  a 
great  deal  of  good  in  cases  of  prolapsus  in  the  first,  and  sometimes 
even  in  the  second  degree.  The  buttocks  being  elevated,  the 
uterus  retreats  from  the  pelvis,  and  its  supports  are  left  entirely  at 
rest.  Opportunity  is  thus  aftbrded  the  weakened  tissues  to  contract, 
to  gain  tone  and  strength,  and  in  time  to  resume  their  functions. 
The  results  of  posture  may  be  materially  increased  by  simultaneous 
employment  of  the  following  agents. 

Astringents  and  Tojiics. — By  these  means  the  pelvic  tissues  may 
be  made  to  sustain  the  uterus  for  a  time,  and  thus  by  keeping  it 
out  of  danger  of  congestion  from  interference  with  circulation, 
opportunity  is  given  for  removal  of  engorgement  or  slight  hyper- 
trophy. 

The  astringents  most  commonly  employed  are  tannin,  alum, 
})ersulphate  of  iron,  and  the  bark  of  the  white  oak.  They  may 
be  injected  into  the  vagina  in  solution  or  infusion,  by  means  of 


346  PROLAPSUS    UTERI. 

the  ordinary  syringe;  introduced  in  suppositories,  or  applied  to 
the  whole  canal  in  powder,  by  the  vaginal  suppository  tube  repre- 
sented elsewhere. 

Tonics  may  be  locally  applied  by  the  use  of  cold  hip-baths, 
douches,  sea-baths,  and  by  copious  vaginal  injections  of  cold  water, 
salt  and  water,  or  sea  water,  which  is  better. 

General  tonics,  mineral  and  vegetable,  should  be  employed. 
Among  these,  ergot,  strychnia,  and  iron  may  be  specially  men- 
tioned. Sea-bathing  is  peculiarly  beneficial  for  this  purpose,  for  it 
not  only  acts  locally,  but  improves  the  tone  of  the  whole  system. 

Pessaries. — The  plan  of  sup])orting  the  i)rolapsed  uterus,  vagina, 
bladder,  and  rectum  by  mechanical  contrivances  which  supi)lement 
the  enfeebled  natural  supports  constitutes  a  method  of  great  value, 
and  one  which  will  never  be  cast  aside.  In  a  great  many  cases, 
objections,  or  advanced  age  on  the  part  of  the  jjatient,  want  of 
skill  on  that  of  the  physician,  and  the  uncertainty  as  to  result  which 
attaches  to  all  surgical  procedures  for  the  cure  of  prolapse,  render 
a  resort  to  a  method  which  relieves  very  greatly  during  even  a 
long  lifetime,  one  which  is  dictated  by  prudence  and  good  sense. 
To  support  four  organs,  which  are,  and  have  been  for  a  long  time, 
prolapsed,  by  an  artificial  mechanical  means,  frequently  taxes  the 
skill  of  the  ablest  gynecologist,  and  sometimes  utterly  defeats  his 
best  attempts.  Let  the  general  practitioner  bear  this  undeniable 
fact  in  mind,  and  not  become  discouraged  by  difficulties,  nor  dis- 
heartened by  repeated  fruitless  eftbrts.  Let  such  a  one  who  reads 
this  believe  too  the  assertion  which  I  here  make,  that  I  advise  no 
instrument  merely  because  it  has  been  generally  accepted,  and  that 
I  limit  myself  to  the  mention  of  those  only  which  I  daily  employ 
in  practice  with  good  results. 

In  employing  pessaries  for  all  the  varieties  of  prolapsus  of  the 
pelvic  organs,  the  desideratum  is  an  instrument  which  will  not 
distend  tlie  vagina,  at  the  same  time  that  it  will  support  the  uterus. 
Such  instruments  as  sustain  the  vagina  without  distending  it,  and 
thus  allow  it  to  regain  something  of  its  former  tone  and  elasticity, 
are  those  which  should  be,  as  far  as  possible,  selected.  The  great 
functions  which,  in  the  majority  of  cases,  are  required  of  a  pessary 
in  prolapsus  are  these:  first  to  supplement  the  action  of  the  utero- 
sacral  ligaments,  the  chief  factors  in  sustaining  the  uterus;  second, 
to  keep  the  vagina,  bladder,  and  rectum  in  place,  so  as  to  prevent 
them  from  perpetuating  the  uterine  displacement  by  traction. 

I  have  already  said,  that  he  who  treats  this  condition,  in  any  of 
its  varieties,  by  replacement  and  support  by  a  pessary,  must  fre- 


PESSARIES.  347 

quentlj  meet  with  insuccess.  Is  it  not  illogical  to  suppose  that  by 
any  mechanical  contrivance,  heavy,  congested,  and  prolapsed  organs, 
often  four  in  number,  very  generally  three,  can  be,  without  prepa- 
ration or  the  use  of  allied  means,  kept  at  once  in  normal  position? 
Yet  such  a  result  is  often  anticipated.  Before  resorting  to  a  pessary 
at  all,  the  patient  should  be  kept  in  the  recumbent  posture  for  a 
few  days,  or,  if  possible,  a  week,  with  the  foot  of  the  bedstead 
elevated  six  inches,  for  the  purpose  of  allowing  congestion  to  pass 
oft'.  During  this  time  mild  cathartics  should  be  given  to  further 
this  end  by  removal  of  fecal  matter  and  stimulation  of  hepatic 
circulation,  and  the  vagina  should  be  systematically  and  copiously 
irrigated  with  astringent  fluids  to  harden  its  tissues  in  preparation 
for  a  pessary,  to  effect  support  of  the  uterus,  bladder,  and  rectum 
by  a  re-establishment  of  its  sustaining  power,  and  to  cause  contrac- 
tion in  its  distended  superficial  bloodvessels.  This  time  is  not 
wasted,  for  the  case  is  sure  to  be  a  lengthy  one,  and  at  the  end  of 
it,  the  patient  is  much  better  able  to  begin  treatment  of  a  mechanical 
kind  without  meeting  with  mishaps,  which,  in  the  commencement, 
dishearten  and  discourage  her.  Nowhere  is  the  statement  more  true 
than  here,  that  a  good  beginning  advances  us  half  way  to  success. 

The  patient  having  risen,  all  of  these  means,  except  recumbency, 
should  be  continued  throughout  treatment,  and  others  which  are 
adjuvants  to  the  pessary  should  be  adopted,  as,  for  example,  removal 
of  weight  of  clothing;  avoidance  of  muscular  efforts,  long  standing, 
and  constrained  postures ;  diminution  of  weight  of  uterus ;  and 
others  which  have  been  already  enumerated.  Having  attended  to 
all  these  points  the  pessary  presents  itself  as  a  valuable  resource  by 
which  to  complete  and  effect  restoration  of  the  parts:  without 
attention  to  them  it  is  often  too  feeble  to  accomplish,  unaided,  the 
desired  result. 

Let  us  suppose  that  we  are  dealing  with  a  case  of  prolapse  in 
the  first  or  second  degree,  what  pessary  should  we  choose  ?  This 
will  depend  upon  the  amount  of  weight  to  be  sustained.  If  this  be 
great,  a  fibrous  tumor  existing,  and,  by  its  weight,  depressing  the 
organ,  very  possibly  no  internal  pessary  will  succeed ;  if  it  be 
moderate,  almost  any  one  of  this  list  will  do  so — Meigs's  elastic 
ring,  Hodge's,  Smith's,  Hewitt's,  or  Thomas's  pessaries,  all  of  which 
are  shown  Ijy  diagrams  in  connection  with  retroversion.  None 
should  be  used  which  distends  the  vagina,  and  that  employed  should 
be  worn  without  any  sense  of  discomfort;  should  be  kept  clean  by 
irrigation  with  astringent  fluid  every  night,  or  night  and  morning; 


348 


PEOLATSUS    UTERI, 


and  should  be  examined,  at  intervals,  by  the  physician,  to  make 
sure  that  it  is  not  cutting  into  the  tissues. 

If  the  great  weight  of  the  uterus  render  these  pessaries,  which 
pass  entirely  into  the  body,  ineffectual,  or,  should  the  case  be  one 
of  prolapse  in  the  third  degree,  others,  which  are  in  part  external 
and  in  part  internal,  should  be  employed.  I  rarely  attemjit  to  sus- 
tain a  completely  prolapsed  uterus  by  an  internal  pessary,  because  I 
usually  despair  of  success,  and  because  I  have  known  such  evil  con- 
sequences result  from  them  in  such  cases,  that  I  am  unwilling  to 
let  the  patient  pass  out  of  my  sight  with  one  in  place.  It  is  safer, 
more  effectual,  and  more  comfortable  for  both  jdiysician  and  patient 
that  she  should  wear  an  instrument  which  she  can  remove  at  will, 
allow  the  parts  to  rest  during  the  hours  of  recumbency,  and  replace 
upon  rising. 

There  are  three  methods  by  which  such  support  may  be  furnished, 
by  a  stem  curling  over  the  perineum,  by  one  passing  out  of  the 
vagina  over  the  symphysis  pubis,  and  by  one  ending  at  the  middle 
of  the  vulvar  opening,  and  resting  upon  a  bandage  passing  beneath 
it.  Of  these  plans,  the  best  is  the  first,  and  the  next,  in  merit, 
the  second.  The  third  is  objectionable,  on  account  of  the  want  of 
some  point  of  support  against  which  to  fix  the  distal  extremity  of 
the  stem,  and  prevent  motion  in  it. 

No  pessary  with  which  I  am  acquainted,  so  universally  answers 
the  indications  of  supplementing  the  action  of  the  utero-sacral 
ligaments  and  sustaining  the  prolapsed  vagina,  rectum,  and  bladder 
as  Cutter's  admirable  pessary  shown  in  Fig.  87.     The  cup  at  its 

Fig.  87. 


Cutter's  prolapsus  pessary  in  position. 


Prolapsus  pessary  with  abdominal 
support. 


PERINEORRHAPHY,  349 

upper  extremity  receives  the  cervix  uteri,  and  the  simplicity  of  the 
instrument  enables  the  patient  to  remove  and  replace  it  with  per- 
fect facility.  This  should  be  doue  in  the  recumbent  posture  upon 
retiring  at  night  and  rising  in  the  morning. 

By  reversing  the  direction  of  the  stem,  it  may  in  a  similar 
manner  be  carried  over  the  symphysis  pubis  and  attached  to  a 
belt  passed  around  the  waist.  Fig.  88  shows  such  an  instrument 
in  position. 

Means  Jor  'preventing  traction  by  the  vagina. 

Perineal  support; 
Perineorrhaphy ; 
Ely  t  ro  r  rh  aphy . 

Perineal  Support. — I  have  already  pointed  out  the  important 
function  of  the  perineal  body  in  closing  the  mouth  of  the  vagina 
and  offering  a  buttress  for  the  support  of  its  walls.  When  rupture 
of  the  perijieum  occurs,  its  sphincteric  powers  are  destroyed,  and 
the  result  is  sagging  of  one  or  both  columns  of  the  vagina  and 
coincident  descent  of  the  uterus.  By  firm  pressure  at  the  weak 
spot,  by  means  of  a  pad  or  cushion  filled  with  hair,  cotton,  or  air, 
and  combined  with  an  abdominal  supporter,  to  which  it  may  be 
attached,  partial  relief  is  sometimes  obtained. 

Perineorrhaphy. — Much  more  complete  and  permanent  support 
may  be  given  to  the  vagina,  and  prolapse  of  its  walls  be  much  more 
certainly  obviated,  by  restoration  of  the  perineal  body  by  the  ope- 
ration of  perineorrhaphy.  If  the  uterus  be  not  very  heavy,  this 
operation  often  proves  a  very  excellent  means  of  relief,  for  it 
removes  the  tractile  power,  which  pulls  down  this  organ,  and 
thus  the  cause  of  the  accident  is  taken  away.  But  this  opera- 
tion, although  efiicient  in  these  cases,  is  not  likely  to  prove  so 
where  so  heavy  a  weight,  as  a  much  enlarged  uterus,  requires 
support. 

It  must  not  be  supposed  that,  in  cases  of  prolapsed  vagina, 
perineorrhaphy  is  limited  to  instances  in  which  the  perineum  is 
ruptured.  It  is  equally  applicable  to  those  in  which  the  pressure 
of  a  voluminous  and  heavy  vagina  or  uterus  has  produced  com- 
plete loss  of  power  in  the  perineal  body,  and  caused  its  disten- 
tion and  attenuation.  In  all  cases,  to  be  effectual,  it  must  restore 
the  lost  organ,  the  perineal  body,  and  not  simply  shut  the  evil  from 
sight  by  drawing  before  it  a  thin  and  useless  curtain,  which  ex- 
tends from  the  fourchette  to  the  anus. 


350  PROLAPSUS    UTERI. 

JElT/trorrhaphy.^—The  idea  of  constricting  the  vagina  so  as  to 
diminish  its  capacity,  and  at  the  same  time  oiler  a  column  of  cica- 
tricial material  for  the  support  of  the  uterus,  long  ago  suggested 
itself  to  the  minds  of  .practitioners  for  the  relief  of  prolapsus  uteri. 
In  1823,  M.  Remain  Gerardin  made  the  suggestion  hefore  the 
Medical  Society  of  Metz,  but  the  operation  does  not  appear  to  have 
been  essayed,  for  the  writer  with  a  great  deal  of  patriotic  zeal 
states  in  a  subsequent  essay^  upon  the  subject,  that  "  his  desire  had 
been  to  put  beyond  controversy  the  origin  of  the  operation,  and  to 
preserve  for  French  surgery  the  priority  of  its  conception,  if  not 
of  its  execution."  While  this  surgeon  was  felicitating  his  country 
upon  the  conception  of  an  idea,  Dieffenbach,  in  Germany,  and 
Heming,  in  England,  proved  its  practicability  by  absolute  perform- 
ance. Dieffenbach  probably  operated  as  earl}^  as  1830,  as  a  report 
of  his  having  done  so  was  published  in  a  foreign  journal  in  June, 
1831.  In  ITovember,  1831,  the  late  Dr.  Marshall  Hall,  of  England, 
published  a  case,  in  which  at  his  suggestion  it  had  been  performed 
by  Dr.  Heming,  the  translator  of  Boivin  and  Dug^s  on  the  Diseases 
of  the  Uterus,  with  complete  success.  Subsequent  to  this  period 
it  was  performed,  with  various  modifications,  by  Fricke,  Scanzoni, 
Velpeau,  Roux,  Stolz,  and  others ;  the  operation  always  consisting 
in  "  the  removal  of  a  band  of  vaginal  mucous  membrane  and  union 
of  the  two  lips  of  the  wound  in  such  a  manner  as  to  diminish  the 

calibre  of  the  vagina Dieffenbach  refers  to  a  great  number 

of  women  who  were  completely  cured  by  the  procedure 

Fricke  out  of  four  cases  cured  three. "^  Judging  from  these  quota- 
tions, it  appears  that  the  operation  has  l)een  known  and  practised 
for  a  long  time  on  the  continent  of  Europe,  especially  in  Germany. 
In  England  it  has  not  been  resorted  to,  if  we  may  judge  from  the 
statement  of  Dr.  Sims,*  that  after  a  discussion  upon  an  essay  pre- 
sented by  himself  to  the  London  Obstetrical  Society,  Mr.  Spencer 
Wells  called  his  attention  to  the  operation  of  Mr.  Heming,  already 
referred  to,  with  the  assertion  that  "at  least  one  case  had  been 
successfully  operated  upon." 

The  operation,  probably  for  reasons  which  I  shall  mention  here- 
after, had  fallen  entirely  into  disuse  when  Dr.  Sims^  revived  it  in 
1858,  with  certain  modifications.     His  operation,  which  I  shall  now 

'  tJiDi-pov,  "the  vagina,"  and  po^,  "suture." 

^  Gazette  M6dicale,  1835,  p.  558. 

"  Wieland  and  Dubrisay,  op.  oit.,  p.  533. 

*  Uterine  Surgery,  Am.  ed..  p.  312. 

^  Uterine  Surgery,  Eng.  ed.,  p.  309. 


ELYTRORRHAPHY. 


351 


proceed  to  describe,  differs  very  essentially  from  that  adopted  by 
his  predecessors. 

Sims's  Operation  of  Elytrorrhaphy. — The  patient,  being  put  under 
the  influence  of  an  anaesthetic,  is  laid  upon  a  table,  upon  the  left 
side  as  for  an  ordinary  speculum  examination,  and  Sims's  largest 
speculum  introduced.  A  curved  sound,  with  forked  tenaculum 
points,  is  fixed  in  the  cervi^Q  uteri  and  made  to  cause  a  fold  in  the 
anterior  vaginal  wall,  as  shown  in  Fig.  89. 


Fig.  89. 


Cterns  fixed  by  sound.     (Sims.) 

The  parts  being  steadied  by  this  instrument,  the  operator,  by 
means  of  two  tenacula,  folds  over  the  opposite  walls  of  the  vagina 
so  as  to  decide  where  union  is  to  be  effected.  Havino-  settled  this 
point,  the  mucous  membrane  is  hooked  up  by  a  tenaculum  several 
lines  above  the  meatus  and  cut  by  curved  scissors.  The  tenaculum 
lifting  the  piece  thus  cut,  and  when  necessary  being  again  attached 
to  the  mucous  membrane,  the  incision  is  carried  upwards  so  as  to 


352 


PROLAPSUS    UTERI. 


cut  out  a  strip  extending  to  one  side  of  the  cervix.  Then  another 
furrow  is  cut  in  the  same  manner  on  the  other  side. 

The  sound  being  removed,  and  the  cervix  pulled  down  by  a  small 
tenaculum,  two  transverse  lines  of  denudation,  not  shown  in  the 
diagram,  nearly  uniting  the  two  arms  of  the  Y,  are  made. 

Sutures  of  silk  are  then  inserted  after  the  plan  employed  in  vagi- 
nal fistulse,  and  by  them-  silver  sutures  are  drawn  into  position. 
The  passage  of  sutures  should  be  commenced  at  the  apex  of  the 
triangle  and  continued  upwards. 

The  after-treatment  consists  in  perfect  quietude  in  the  horizontal 
posture,  the  use  of  opium,  frequent  removal  of  urine  by  a  catheter, 
and  the  production  of  constipation.  The  lower  sutures  may  be 
removed  in  ten  days,  and  the  upper  in  a  fortnight.  The  patient 
should  be  kept  in  the  recumbent  posture  for  two  or  three  weeks, 
and  cautioned  against  immoderate  muscular  effort  for  some  time 
afterwards. 

Dr.  Emmet,  finding  that  the  pouch  left  posterior  to  the  uterine 
neck  by  this  procedure  was  sometimes  entered  by  the  cervix,  im- 


Fig.  90. 


Emmet's  operation  of  elytrorrhaphy. 


proved  the  operation  by  closing  it,  as  represented  in  Fig.  90.     He 
has  since  the  introduction  of  this  procedure  still  furthersimplified 


ELYTROREHAPHY.  353 

it,  111  the  following  manner.  At  the  commencement  he  catches  up 
with  a  tenaculum  a  patch  of  mucous  membrane  at  the  proper  dis- 
tance to  one  side  of  the  cervix,  and  with  scissors  snips  this  out. 
On  the  other  side  he  does  the  same  thing,  and  also  on  the  posterior 
wall  of  the  cervix.  He  then  passes  a  wire  suture  so  as  to  bring  all 
these  denuded  points  together,  face  to  face,  and  twists  the  wire  so 
as  to  hold  them  tos-ether.  The  result  is  that  the  foldins:  of  the 
vagina  accomplished  by  the  sound,  as  shown  in  Fig.  89,  occurs 
without  the  use  of  that  instrument.  Catching  up  a  piece  of  mucous 
membrane  on  tJie  vaginal  fold  of  each  side  with  the  tenaculum, 
he  now  cuts  it  out  and  at  once  passes  a  suture,  and  thus  he  pro- 
ceeds, step  by  step,  avoiding  a  great  flow  of  blood  and  opposing 
the  abraded  surfaces  immediately,  accurately,  and  without  danger 
of  passing  the  sutures  so  that  they  will  not  be  symmetrical.  I 
have  performed  the  operation  several  times  after  this  plan,  and 
can  bear  testimony  to  its  simplicity. 

That  the  operation  of  elytrorrhaphy  has  effected  excellent  results, 
there  can  be  no  doubt,  for  the  journals  of  the  day  contain  nume- 
rous reports  of  cases  successfullj^  operated  upon  by  slight  modifica- 
tions of  it.  Its  disadvantages  are,  that  it  is  a  veiy  tedious  process, 
diflicult  of  performance  for  one  not  familiar  with  this  kind  of  sur- 
gery, and  liable  to  failure  even  if  carefully  and  thoroughly  accom- 
plished. Further  than  this,  it  is  unquestionable  that  in  a  large 
number  of  cases  expansion  of  the  vagina  recurs  in  time  in  spite 
of  it.  Scanzoni^  goes  so  far  as  to  say  that  the  operation  always 
fails.  After  employing  it  thirteen  times^  he  says :  "  From  the  re- 
sults obtained  in  our  own  cases,  w^e  can  by  no  means  pronounce 
favorably  on  these  operations."  Courty^  says,  in  sj^eaking  of  the 
operation,  "  The  majority  of  surgeons  to-day  regard  as  useless  a 
method  of  treatment,  which  is  besides  not  devoid  of  danger."  A 
reviewer  of  the  !New  York  Medical  JournaP  says :  "  We  have  now 
under  our  charge,  a  patient  operated  upon  nine  years  ago  by  Sims's 
method ;  in  a  year  the  cicatrices  had  given  way,  and  the  procidentia 
returned.  Three  years  ago,  she  was  operated  on  twice  by  Emmet's 
method ;  in  little  more  than  a  year  the  bands  gave  way,  and  her 
condition  was  worse  than  before,  for  the  vagina  was  so  deformed 
by  the  cicatrices  that  it  became  imj)Ossil)le  to  adjust  a  j)essary."  I 
shall  not,  however,  strive  to  accumulate  evidence  of  this  kind ;  I 
have  oftered  this  merely  to  sustain  my  statement  that  there  are 
certain  disadvantages  attaching  to  the  procedure.     Having  experi- 

»  Op.  §it.,  p.  159.  2  Mai.  de  I'Uterus,  p.  748.  »  To),  .viii,  p.  523. 

23 


354  PROLAPSUS    UTERI. 

encecl  some  of  these  in  practice,  I  have  performed  a  different  opera- 
tion for  the  same  purpose,  namely,  removing  a  portion  of  the 
entire  vaginal  wall,'  by  a  process  which  prevents  the  possibility  of 
severe  hemorrhage,  at  the  same  time  that  it  secures  complete  appo- 
sition of  the  lips  of  the  wound.  I  have  now  resorted  to  this  pro- 
cedure fourteen  times.  All  of  my  cases,  however,  have  occurred 
in  hospital  practice,  and  of  most  I  have  lost  sight.  From  those 
which  I  have  been  able  to  follow,  I  feel  that  I  can  speak  with 
increasing  confidence  of  the  plan.  By  this  method  there  is  an 
entire  removal  of  a  portion  of  the  vaginal  wall,  so  that  if  expansion 
again  occurs  it  must  do  so,  not  by  tearing  asunder  adherent  walls, 
but  by  stretching  of  the  whole  canal. 

Thomases  Operation  for  Narrowing  the  Vagina. — This  operation 
may  be  performed  upon  either  one,  or  both  of  the  vaginal  walls  in 
two  successive  operations.  In  doing  it,  the  uterus  may  in  the  first 
operation  be  left  in  a  state  of  complete  prolapse,  or  it  may  be  returned 
to  the  pelvis,  and  the  procedure  accomplished  with  Sims's  speculum 
in  the  vagina.  Let  us  suppose  it  applied  to  the  anterior  wall  while 
the  uterus  is  in  a  state  of  prolapsus.  The  patient  having  been  ether- 
ized and  placed  upon  the  back,  a  portion  of  the  vagina,  about  half 
an  inch  to  one  side  of  the  cervix,  is  caught  up  with  the  tenaculum, 
and  a  piece  the  size  of  a  buckshot  cut  out  with  scissors.  Through 
this  opening  a  grooved  director  is  passed  directly  across  the  ante- 
rior face  of  the  uterus,  and  between  it  and  the  vagina  to  a  point 
on  the  other  side,  corresponding  to  that  wliich  marked  the  com- 
mencement of  the  operation.  Upon  this  director  the  vagina  is  cut 
transversely.  Entering  the  director  now  at  the  middle  point  of 
the  transverse  cut,  it  is  gradually  insinuated  through  the  loose 
areolar  tissue  between  the  bladder  and  the  vagina,  until  it  reaches 

Fig.  91. 


G.T  lE:MA^N-CO. 

Dilating  forceps  for  separating  the  bladder  and  vagina. 

a  point  near  the  meatus,  when  it  is  withdrawn.  This  insertion  I 
have  found  quite  easy.  An  instrument  of  steel,  Fig.  91,  six  inches 
long,  shaped  like  an  ordinary  glove  stretcher,  with  limbs  equal  in  size 
to  a  ISTo.  9  steel  sound  and  three  inches  long,  is  then  passed  down 

'  Removal  of  portions  of  the  vaginal  wall  was  long  ago  practised  by  Dieffenbach 
and  others.     It  is  only  the  method  of  doing  it  which  is  mine. 


NARROWIXG    THE    VAGINA.  355 

the  cliannel  made  by  the  sound.  When  the  lowest  point  of  this  is 
reached,  the  blades  are  thrown  apart  by  approximation  of  the 
handles,  and  a  subcutaneous  tearing  is  accomplished,  so  as  to 
separate  the  bladder  from  the  vagina  over  a  triangular  sj^ace,  the 
apex  of  which  is  at  the  urethra  and  the  base  at  the  cervix.  If  the 
tissue  does  not  yield  readily,  the  finger  is  made  to  aid  the  stretcher, 
and  the  separation  is  rapidly  accomplished.  A  clamp,  three  inches 
long,  with  blades  half  an  inch  wide,  and  having  two  rows  of  teeth, 
a  quarter  of  an  inch  in  length,  fixed  upon  their  inner  faces,  is  then 
applied. 

Fig.  92. 


Clamp  with  teeth  for  compressing  wound  in  vagina. 

This  clamp,  the  limbs  of  which  are  united  by  a  hinge,  admitting 
a  separation  of  a  quarter  of  an  inch  at  one  extremity,  is  united  by 
Va  screw  at  the  other,  which  can  be  graduated  as  to  the  degree  of 
compression  which  it  accomplishes.  The  separated  vagina  is  then 
brought  together  by  a  suture  at  the  cervix,  which  passes  through 
it  at  the  point  where  the  operation  was  commenced.  Tliis  being 
tightened,  the  free  portion  of  the  vagina  is  folded  so  as  to  protrude 
as  two  flaps  turned  face  to  face.  The  clamp  is  then  adjusted,  with 
the  hinge  towards  the  cervix  and  the  screw  towards  the  urethra, 
and  tightened  by  the  screw.  Then  the  portion  of  the  vagina  hanging 
out  of  the  clamp  is  cut  olF  near  the  edge  of  the  clamp,  interrupted 
silver  sutures  are  passed  so  as  to  secure  the  lips  of  the  wound,  and, 
the  clamp  still  in  place,  the  uterus  is  replaced,  a  procedure  involv- 
ing no  difficulty.  The  vagina  is  then  filled  with  a  tampon  of  cot- 
ton wet  with  solution  of  alum  and  carbolic  acid.  This  is  applied 
quite  firmly,  so  as  to  control  any  hemorrhage  which  may  occur 
from  the  transverse  incision  near  the  cervix,  or  from  the  torn  recto- 
vaginal septum. 

The  patient  is  then  put  to  bed,  all  discomfort  quieted  by  opiates, 
the  bladder  emptied  by  the  catheter,  and  the  bowels  kept  consti- 
pated. In  twenty-four  hours  the  tampon  should  be  removed,  in 
forty-eight  the  clamp  should  be  taken  ofiP,  and  in  eight  or  nine 
days  the  sutures  withdrawn. 

Usually  both  walls  require  operation,  an  interval  of  two  or 
three  weeks  intervening  between  the  procedures.     Between  the 


356  PKOLAPSUS    UTERI. 

operation  on  the  vaginal  wall  after  restoration  of  the  uterus  to  its 
place  and  that  where  the  uterus  is  prolapsed  there  is  this  differ- 
ence: in  the  first  case,  the  uterus  being  in  the  pelvis  at  the  time  of 
operation,  the  transverse  incision  would  prove  difficult  of  accom- 
plishment, and  should  not  be  made.  Tlie  opening  in  the  vaginal 
wall  should  be  made  just  above  the  fourchette,  and  through  this 
the  stretcher  introduced.  After  separation  of  the  vagina  from  the 
rectum,  the  clamp  is  applied  and  the  overlapping  vagina  cut  off. 

I  am,  of  course,  not  yet  in  a  position  to  speak  with  jjositiveness 
of  this  procedure,  but  these  are  the  advantages  which  I  think  that 
it  presents.  It  involves  not  the  mere  adhesion  of  the  vaginal 
walls,  but  entire  removal  of  a  portion,  and  this  absolutely  narrows 
the  vagina  by  a  cicatricial  band,  which  is  not  susceptible  of  being 
sundered.  The  operation  being  performed  by  subcutaneous,  or 
rather  submuscular  tearing  of  areolar  tissue  and  compression  by 
clamp,  hemorrhage  is  not  likely  to  occur  from  these  vascular  tissues. 
The  clamp  not  being  amenable  to  having  its  teeth  tear  out  by 
traction,  movements  on  the  part  of  the  patient,  coughing,  vomiting, 
etc.,  are  not  likely  to  result  in  failure  as  in  the  ordinary  procedure. 
The  entire  procedure  can  always  be  accomplished  by  an  ordi- 
narily expeditious  operator  within  thii'ty  minutes,  which  greatly 
redounds  to  the  advantage  of  the  patient. 

My  experience  thus  far  with  this  operation  has  acquainted  me 
with  but  one  disadvantage  connected  with  it,  that  is,  liemorrhage; 
but  this  has  always  proved  controllable  by  means  of  the  clamp. 
This  should  of  course  be  carefully  regulated  as  to  the  amount  of 
pressure  which  it  is  made  to  exert,  in  order  to  avoid  interference 
with  the  nutrition  of  the  compressed  part. 

The  clamp  which  I  employ  may  be  made  either  of  nickelized 
steel  or  of  vulcanite.  The  steel  stretcher  may  be  dispensed  with, 
and  the  tearing  of  the  areolar  tissue  accomplished  by  a  sound. 

It  is  never  safe  to  promise  a  good  and  permanent  result  from  any 
of  the  operations  of  elytrorrhaphy.  If  in  a  case  of  enlargement 
of  the  cervix,  relaxation  of  the  vagina,  and  complete  distention  or 
rupture  of  the  perineum,  the  patient  is  willing  to  submit  to  three 
operations,  amputation  of  the  cervix,  elytrorrliaphy  upon  anterior 
wall,  and  closure  of  the  perineum,  cure  will  often  be  complete  and 
permanent.  This  is  a  trying  ordeal,  both  mentally  and  physically; 
nevertheless  most  women  affected  by  prolapsus  in  the  third  degree 
would  unhesitatingly  accept  one  of  even  greater  severity  with  the 
prospect  of  cure. 

Besides  the  operations  here  mentioned  as  practised  upon  the 


ANTEVERSION    OF    THE    UTERUS.  357 

vaginal  walls,  Episiorrhapliy,  wliicli  has  been  already  described,  has 
at  various  times  been  resorted  to  as  a  curative  or  palliative  process 
for  the  affection  of  which  we  are  treating.  This,  too,  has  been 
variously  combined  and  modified,  as,  for  example,  under  the  names 
of  Inferior  Elytrorrhaphy,  Elytro-episiorrhaphy,  Episio-perineor- 
rhaphy,  etc.  For  fear  of  confusing  the  subject  by  the  introduction 
of  details  Avhich,  although  highly  interesting,  are  of  no  great  prac- 
tical value,  I  shall  not  describe  these  modified  procedures,  but  pass 
them  by  with  this  mention. 

]S"ot  only  have  efforts  of  this  kind  been  made  for  narrowing  the 
vagina  and  creating  an  artificial  cicatricial  anterior  or  posterior 
column  for  the  support  of  the  uterus ;  the  actual  canter}- ,  mineral 
acids,  escharotics,  ulceration  created  by  galvanic  pessaries,  and 
sloughing  produced  by  pressure  by  forceps,  have  all  been  tried  for 
the  accomplishment  of  the  much-desired  end,  I  shall  not  go  into 
the  detail  of  describing  these  procedures,  but  refer  the  reader,  who 
desires  further  information  upon  them,  to  Scanzoni's  work  upon 
the  Diseases  of  Feniales.  All  these  methods  have  the  disadvantages 
of  proving  excessively  painful,  after  anaesthetic  influence  has  passed 
off,  and  of  being  more  unmanageable  and  less  certain  in  their 
results  than  those  here  described. 


CHAPTER    XXI. 


ANTEVERSION  OF  THE  UTERUS. 


In  treating  of  versions  and  flexions  under  separate  heads,  I  would 
especially  guard  the  reader  against  supposing  that  a  clear  and  dis- 
tinct line  is  to  be  drawn,  clinically,  between  them.  I  have  deemed 
it  conducive  to  completeness  and  thoroughness  of  detail  to  deal  with 
them  in  this  way,  but  versions  are  rarely  uncomplicated  with 
flexions,  and  flexions  are  frequently  complicated  by  them. 

Definition  and  Frequency. — This  disorder  of  position  consists  in 
an  anterior  inclination  of  the  uterus,  so  that  the  fundus  approxi- 
mates the  symphysis  pubis  and  the  cervix  retreats  into  tlie  hollow 
of  the  sacrum.     Although  not  so  frequent  as  its  kindred  condition, 


358  ANTEVEESION    OF    THE    UTEEUS. 

anteflexion,  it  is  by  no  means  of  rare  occurrence.  At  times  it 
presents  itself  as  an  annoying  complication  of  areolar  hyperplasia 
or  fi.broid.  growths,  while  at  others  it  is  produced  without  any 
alteration  existing  in  the  uterine  parenchyma. 

Dr.  ChurchilP  opens  his  chapter  upon  this  subject  with  these 
words :  "  It  may  be  thought  somewhat  out  of  place  to  treat  of  some 
of  these  displacements  here,  as  they  are  so  intimately  connected 
with  pregnancy  and  parturition ;  but  as  they  do  occur  independentlj', 
it  appears  to  me  preferable  to  travel  so  far  out  of  the  way  in  order 
to  complete  the  subject,  rather  than  give  a  partial  view,  or  omit  it 
altogether."  My  own  experience  leads  me  to  an  entirely  different 
conclusion  from  that  here  recorded  by  the  eminent  Irish  obstetrician. 
I  meet  with  versions  very  commonly  in  the  non-puerperal  state.  M. 
Goupil,  in  115  examinations  of  nulliparous  women,  met  with  version 
or  flexion  14  times;  and  in  114  examinations  of  multiparas  he  found 
it  in  36  instances. 

The  following  table  is  one  constructed  from  a  valuable  statistical 
report  by  Dr.  Meadows: 


Number  of  cases  of  displacement  examined 
"  "  posterior  displacement 

"  "  anterior  displacement         32 


posterior  displacement      52  j  R<?troflexion 

(.  Retroversion 
Anteflexion 
Ante  version 


84 
•34 
18 
20 
12 


It  is  impossible  to  reconcile  the  discrepancy  of  the  results  ob- 
tained by  statistical  evidence  accumulated  by  different  observers. 
Thus,  for  example,  out  of  339  cases  of  displacement  recorded  by 
M.  Nonat,2  the  following  were  the  number  of  anterior  and  posterior 
inclinations : 

Auteversion 135 

Anteflexion 33 

Retroversion  ........  67 

Retroflexion X4 

"  Anteversion,"  says  Klob,^  "  in  general  is  a  rare  form  of  displace- 
ment, and  occurs  much  less  frequently  than  retroversion." 

Subjects  of  this  character  belong  to  that  class  upon  which 
reasoning  and  theorizing  accomplish  no  good,  but  rather  the  con- 
trary. The  only  way  in  which  they  can  be  settled  is  by  carefully 
collected  statistics,  and  one  would  suppose  that  this  method  would 

'  Diseases  of  Women,  Am.  ed.  2  j^^l.  de  I'Uterus,  p.  416. 

^  Klob,  Patholog.  Aiiat.,  p.  69. 


DEFINITION    AND    FEEQUENCY. 


359 


be  conclusive.  Yet  we  see  in  the  present  case  how  far  this  is  from 
being  the  fact.  Dr.  Meadows's  most  frequent  displacement  is  M. 
jS'onat's  and  Scanzoni's  least  frequent !  Nothing  but  discrepancy 
and  doubt  result  from  the  comparison  of  the  figures  of  these  three 
conscientious  observers.  "  There  is  nothing,"  said  Sydney  Smith, 
"so  unreliable  as  figures,  except  facts."  After  such  a  comparison 
of  statistical  evidence  one  feels  inclined  to  agree  with  him. 

The  normal  position  of  the  uterus  is  one  of  slight  anteversion, 
the  axis  of  the  body  corresponding  with  that  of  the  superior  strait, 
which  is  a  line  running  from  the  umbilicus,  or  a  little  above  it,  to 
the  coccyx. 

Fiff.  93. 


Normal  position  of  uterus.'    (Breisky.) 


The  degree  of  this  forward  inclination  may  be  so  increased  by 
slight  causes  as  to  constitute  a  morbid  state.  As  to  the  line  which 
separates  what  is  normal  from  what  is  abnormal,  it  is  impossible 
to  lay  down  any  exact  rule;  experience  must  be  our  guide.  In 
general  terms  we  may  say,  that  when  the  long  axis  of  the  uterus 
is  found  lying  across  the  pelvis,  the  fundus  near  the  symphysis 
pubis,  and  the  neck  in  the  hollow  of  the  sacrum,  anteversion  exists. 

The  chief  factors  in  the  suspension  of  the  uterus  are  the  utero- 


■  Boston  Gynaecol.  Journ. 


360  ANTEVERSION    OF    THE    UTERUS. 

vesical  and  utero-sacral  ligaments  which  attach  themselves  to  it  at 
the  junction  of  the  neck  and  hodj.  This  point,  therefore,  consti- 
tutes what  has  been  termed,  its  "centre  of  revolution."  Thus 
poised,  it  is  kept  from  revolving  anteriorly  hy  the  broad  ligaments 
and  a  cei'tain  degree  of  support  furnished  by  the  bladder  and  abdo- 
minal walls.  Any  influence  which  overcomes  or  abolishes  the 
sustaining  power  of  the  bladder,  the  utero-vesical  ligaments,  or 
walls  of  the  abdomen,  either  excites  such  change  of  position,  or 
renders  the  uterus  peculiarly  predisposed  to  it  from  causes  of  excit- 
ing kind. 

Pi-edisposing  Causes. — The  predisposing  causes  of  this  aftection 
are  parturition,  enfeebled  muscular  condition,  habits  of  indolence 
and  inactivity,  and  loss  of  tone  in  the  abdominal  walls. 

The  exciting  causes  may  thus  be  presented: 

Influences  increasing  the  weight  of  the  uterus- 

Congestion ; 

Hypertrophy  or  hyperplasia ; 

Subinvolution ; 

Fibroids; 

Pregnancy. 
Influences  forcing  the  fundus  directly  forwards. 

Violent  eiforts ; 

Abdominal  eftusions; 

Abdominal  tumors; 

Tight  clothing. 
Influences  enfeebling  uterine  supports. 

Ruptured  perineum; 

Prolapsus  vaginse ; 

Relaxation  of  ligaments; 

Destruction   of  power  of    utero-vesical   ligaments   by 
cystocele. 

Influences  dragging  the  fundus  directly  forwards. 
False  membranes; 
Prolapsus  vaginae ; 
Cystocele ; 

Shortness  of  the  round  ligaments;  (?) 
Anteflexion. 

A  large  number  of  cases  will  be  found  due  to  areolar  hyperplasia, 
a  number  by  no  means  inconsiderable  to  fibrous  tumors,  some  of 
the  most  irremediable  cases  to  false  membranes,  many  to  cystocele 
which  takes  away  support  at  the  same  time  that  it  produces  traction. 


COURSE,    DURATION,   AND    TERMINATION.  361 

while  a  few  will  exist  without  other  apparent  cause  than  direct 
pressure  from  some  power  which  forces  down  the  abdominal  vis- 
cera upon  the  fundus.  The  last  cause  is  much  aided  by  laxity  of 
the  abdominal  w^alls,  which  robs  the  viscera  of  support. 

Symptoms. — In  a  certain  number  of  cases  ante  version  will  be 
found  to  exist  without  creating  any  disturbance  either  constitu- 
tional or  local.  This,  however,  is  a  rare  exception  to  a  general 
rule.  By  pressure  of  the  os  against  the  posterior  vaginal  wall, 
anteversion  commonly  induces  dysmenorrhcea  and  sterility,  and  by 
pressure  of  the  fundus  against  the  bladder,  and  the  cervix  against 
the  rectum,  these  viscera  are  irritated  and  interfered  with  in  their 
functions.  The  bladder  more  especially  suffers,  sometimes  a  state 
bordering  upon  cystitis  being  engendered.  Pressure  upon  the 
rectum  more  rarely  produces  tenesmus  and  a  painful,  irritable  state. 
In  exceptional  cases  it  is  surprising  to  see  to  how  great  an  extent 
locomotion  is  affected  by  this  condition.  My  experience  furnishes 
me  with  four  cases  in  which  patients  were  for  long  periods  confined 
to  bed  or  the  lounge  on  this  account.  In  one  of  these  the  patient 
had  not  left  the  house  for  four  years ;  in  another  she  had  scarcely 
assumed  the  upright  posture  for  eight  months;  the  third  was  the 
counterpart  of  the  second ;  while  in  the  fourth  the  patient  for 
twelve  years  had  never  walked  over  a  quarter  of  a  mile  without 
serious  inconvenience.  In  each  of  these  cases  positive  proof  was 
afforded  me  of  the  agency  of  anteversion  in  producing  the  disability 
which  existed,  by  its  removal  when  the  uterus  was  properly 
sustained  by  an  anteversion  pessary,  and  by  relapse  at  once  recur- 
rino;,  when  without  her  knowledge  she  was  left  without  its  support. 
Not  one  of  these  women  was  suffering  from  that  hysterical  condi- 
tion which  so  often  misleads  the  physician  as  to  the  results  of 
remedies. 

Course^  Duration,  and  Termination. — Even  if  the  exciting  cause 
of  the  condition  be  removed,  it  will  usually  continue,  for  the  broad 
and  utero- vesical  ligaments  have  by  long  distention  become  stretched 
and  enfeebled,  while  there  has  been  simultaneous  contraction  in  the 
utero-sacral  ligaments  from  long  disuse.  The  first  fail  to  aid  the 
fallen  organ;  the  last  help  to  keep  it  out  of  position  by  lifting  the 
cervix  up  against  the  rectum.  Sometimes  cure  is  effected  by  preg- 
nancy, the  displacement  disappearing  as  involution  is  accomplished. 
Usually,  however,  unless  the  exciting  cause  of  the  condition  be 
removed,  and  the  organ  be  kept  in  proper  position  for  a  year  or 
more,  the  displacement  will  continue  unabated. 


362 


ANTEVEESION    OF    THE    UTERUS, 


Varieties. Anteversion  may  be  complete  or  partial.    While  there 

are  three  degrees  of  retroversion  and  of  prolapse,  there  are  but 
two  of  this  displacement,  for  the  axis  of  the  uterine  body  is  natu- 
rally inclined  so  much  forwards  as  to  prevent  us  from  including 
slight  increase  of  inclination  under  the  head  of  disease. 

Fig.  94  will  show  the  varieties  referred  to;  an  inclination  of  45° 
representing  the  first  degree,  or  partial  anteversion,  and  that  of  90° 
the  second  degree,  or  complete  anteversion. 

Fiff.  94. 


<«- 


The  degrees  of  anteversion. 


Diagnosis. — When  in  a  case  of  this  displacement  vaginal  touch 
is  practised,  the  patient  lying  on  the  back,  the  index  finger  passed 
into  the  fornix  vaginae  discovers  that  the  cervix  is  absent.  A 
rapid  investigation  will  prove  that  it  is  not  to  be  found  in  the 
pubic  or  lateral  regions  of  the  pelvis,  and  deep  exploration  with 
two  fingers  will  discover  it  high  up  in  the  hollow  of  the  sacrum. 
The  finger  being  then  passed  towards  the  pubes  will  come  in  con- 
tact with  a  hard  ridge,  which  will  run  towards  the  symphysis. 
Conjoined  manipulation  will  prove  this  to  be  the  body  of  the 
uterus,  and  complete  the  diagnosis.  Should  further  evidence  be 
required,  the  uterine  probe,  very  much  curved,  may  be  passed  into 
the  cavity,  though  this  is  rarely  necessary  and  always  diflicult. 


TKEATMENT.  363 

Differentiation. — Capuron^  tells  us  that  Levret  mistook  the  first 
case  he  saw  for  stone  in  the  bladder,  operated  for  this,  and  sacrificed 
the  life  of  the  patient.  In  spite  of  such  a  grave  mistake  at  the  hands 
of  so  great  an  authority,  it  may  be  stated  that  there  is  no  diseased 
condition  with  which  this  should  be  confounded.  The  disease  in- 
ducing the  displacement  may  not  be  recognized,  or  some  serious 
error  may  be  made  as  to  its  nature,  but  that  does  not  concern  the 
present  subject.  The  recognition  of  the  mere  fact  of  the  antever- 
sion  is  never  ditficult,  if  proper  diagnostic  means  are  brought  to  its 
elucidation. 

Prognosis. — The  prognosis  as  to  any  serious  injury  which  will 
arise  from  the  displacement  is  decidedly  good,  although  there  are 
many  inconveniences  and  discomforts  connected  with  it,  such,  for 
example,  as  vesical  and  rectal  irritation,  neuralgia  in  consequence 
of  compression  of  the  nerves,  and  difficulty  in  locomotion  ;  none 
of  these,  however,  go  on  to  a  dangerous  degree  of  development. 
If  the  condition  be  not  treated  by  mechanical  means,  it  will  prove 
entirely  incurable ;  but  by  these  the  prospect  of  great  improve- 
ment and  even  of  complete  cure  is  very  good.  Important  and 
early  evidences  of  improvement  resulting  from  mechanical  treat- 
ment are  frequently  obtained  in  disappearance  of  dysmenorrhoea 
and  sterility.  It  is  often  difficult  to  remove  the  exciting  cause  of 
anteversion,  and  even  should  this  be  accomplished,  the  uterus  is 
so  prone  to  retain  the  abnormal  position  in  which  it  has  long  been 
kept,  that  great  difiiculty  attends  its  retention  in  normal  position. 
One  of  the  reasons  for  this  is  the  fact,  already  stated,  that  the 
uterine  ligaments  readily  alter  their  proportion  under  certain  in- 
fluences. Thus  during  pregnancy  they  are  all  elongated ;  in  pos- 
terior displacements  the  utero-sacral  ligaments  are  stretched ;  and 
in  anterior  inclination  the  utero-vesical  ligaments  are  similarly 
affected.  As  the  antithesis  of  this  fact,  prolonged  absence  of 
function  causes  contraction  in  these  structures ;  thus  in  ante- 
version  the  utero-sacral  ligaments  are  generally  shortened,  and 
there  is  no  doubt  that  the  round  ligaments  are  similarly  altered. 

Treatment  of  Anterior  Displacements  in  which  Version  'predominates 
over  Flexion. — The  first  point  which  the  practitioner  should  settle 
before  commencing  treatment,  is  whether  the  displacement  is  the 
main  source  of  existing  morbid  phenomena,  or  whether  these  are 
due  to  some  disease  which  underlies  that  condition.  If  he  be  led 
to  regard  it  as  merely  a  coincident  or  resulting  condition  which  is 

'  Mai.  des  Femmes,  p.  202. 


864  ANTEVERSION    OF    THE    UTERUS. 

producing  no  annoyance,  of  course  the  primary  disorder  must  take 
precedence  of  it  in  treatment.  It  is,  however,  futile  to  assume  the 
position  that  not  the  displacement,  but  its  cause,  must  be  the  main 
object  of  attention;  that  if  endometritis,  subinvolution,  or  a  fibroid 
be  its  cause,  they,  and  not  it,  must  be  treated.  Nothing  so  surely 
prevents  success  in  the  management  of  such  cases  as  the  carrying 
into  practice  of  the  theoretical  view  that  support  must  be  confined 
to  those  of  pure,  uncomplicated  disj^lacement.  It  is  very  often  re- 
quired where  this  is  a  result  or  complication  of  other  disease.  We 
are  called  upon  to  alleviate  one  of  the  most  annoying  symptoms  of 
disease  here,  as  we  are  in  so  many  other  instances.  Pessaries  are 
frequently  required  by  the  uterus  as  splints  are  by  a  fractured  bone, 
not  absolutely  as  a  means  of  cure,  but  as  adjuvants  in  treatment, 
by  which  rest  and  freedom  from  pain  can  be  procured  while  the 
healing  process  advances. 

Means  for  Reduction. — In  the  restoration  of  an  anteverted  uterus 
to  its  place,  difficulty  will  rarely  be  experienced,  for,  unlike  retro- 
version, the  displacement  does  not  often  become  complete.  Even 
when  it  does  so,  reduction  may  be  easily  accomplished.  When  it 
proves  difficult,  the  bladder  having  been  emptied  by  the  catheter, 
the  patient  should  be  placed  upon  her  back  on  a  hard  bed  or  table, 
and  all  tight  clothing  removed  from  the  abdomen.  The  operator 
having  oiled  two  fingers  should  then  pass  them  into  the  vagina,  and 
press  their  tips  against  the  body  of  the  uterus,  which  will  have 
forced  the  walls  of  the  bladder  down  before  it.  The  fingers  of  the 
left  hand  being  thus  employed,  the  right  should  be  laid  upon  the 
abdomen,  so  as  to  push  up  the  abdominal  viscera  and  uterus  when 
reduction  is  attempted.  The  patient  is  now  directed  to  fill  the 
lungs  with  air,  and  then  to  expel  it  gently  by  a  prolonged  expira- 
tory act.  As  this  expiration  is  being  finished,  the  operator  presses 
up  the  body  of  the  uterus  by  the  fingers  in  the  vagina,  and  the  ab- 
dominal viscera  and  fundus  by  the  hand  on  the  abdomen.^  He  will 
generally  succeed  at  once  in  replacing  the  organ.  Should  he  not 
do  so,  he  should  repeat  the  process  as  above  described,  until  the 
end  is  attained.  Of  course  where  the  dislocation  is  partial,  resto- 
ration may  be  much  more  easily  effected  ;  but  in  this  case  it  ac- 
complishes nothing,  for  no  sooner  does  the  force  applied  cease,  than 
the  organ  again  falls  out  of  place.     In  such  a  case  the  fundus  is 

'  The  operator  should  be  very  sure  that  the  anteverted  uterus  is  not  bound  down 
by  false  membranes  before  applying  force  for  its  replacement. 


EETAINING    THE    UTERUS    IN    POSITION.  365 

lifted  by  bimanual  manipulation,  then  tlie  hand  on  the  abdomen 
keeping  it  up,  the  finger  in  the  vagina  is  placed  behind  the  cervix, 
and  this  part  is  pulled  forwards  towards  the  symphysis. 

Some  practitioners  rely  for  cure  upon  the  daily  restoration  of 
an  anteverted  or  retroverted  uterus,  but  hopes  thus  based  will 
prove  delusive.  Where  the  version  is  complete  and  sudden,  a 
return  to  the  normal  position  may  be  final ;  but  never  have  I,  in 
a  single  instance,  seen  it  so  result  where  the  displacement  was 
incomplete  and  chronic. 

Means  for  Retahung  the  Uterus  in  Position. — For  this  purpose  we 
have  the  five  following  means: 

The  dorsal  decubitus; 
Prolonged  retention  of  urine; 
Removal  of  pressure  from  the  abdomen ; 
The  abdominal  supporter ; 
Pessaries. 

The  dorsal  decubitus  in  cases  occurring  suddenly,  as  for  example, 
during  pregnancy  or  after  labor,  is  of  great  value,  and  even  in 
chronic  cases  is  an  important  adjuvant  to  treatment  by  pessaries. 
In  the  commencement  of  such  treatment,  at  least,  it  should  be 
always  adopted,  for  two  or  three  hours  every  day,  at  mid-day,  for 
the  purpose  of  affording  a  temporary  rest  to  the  parts. 

Prolonged  retention  of  urine  was  first  recommended  by  Piorry. 
"While  the  patient  is  erect  it  is  a  means  of  no  value,  but  combined 
with  the  dorsal  decubitus,  it  is  certainly,  to  some  extent,  eftectual, 
and  should  always  be  tried.  In  cases  of  pure  anteflexion,  it  is  of 
little  or  no  value,  but,  when  anteversion  predominates,  it  elevates 
the  uterus  and  sustains  it  very  sensibly,  unless  cystocele  exist.  To 
make  these  means  more  effectual,  let  the  foot  of  the  bedstead  be 
elevated  about  twelve  inches.  As  the  bladder  becomes  distended, 
this  sac,  filled  with  water,  is  pressed  against  the  anteverted  uterus, 
from  which  all  weight  is  removed  by  the  upward  inclination  given 
to  the  intestines.  Let  any  sceptic  examine  an  anteverted  uterus 
by  touch,  after  this  is  done,  and  he  will  be  forced  to  yield  to  the 
conviction  of  his  senses.  As  a  method  of  treatment  preparatory  to 
pessaries,  I  would  strongly  recommend  this  plan,  but  only  in  that 
way. 

Removal  of  abdominal  pressure,  by  prohibition  of  tight  clothing, 
of  heavy  skirts  supported  by  the  hips,  and  of  all  constricting  bands 
which  cause  a  substitution  of  abdominal  for  thoracic  respiration,  is 


366  ANTEVERSION    OF    THE    UTERUS. 

too  often  neglected  in  these  cases.  It  is  a  means  of  great  value, 
and  often  gives  as  much  relief  as  any  other  at  our  command. 

The  Abdominal  Supporter. — In  proportion  to  the  disadvantages 
resulting  from  corseting  the  upper  segment  of  the  trunk,  are  the 
advantages  to  be  derived,  in  these  cases,  from  thus  acting  upon  the 
lower.  When  tlie  abdominal  walls  are  lax  and  yielding,  and  do 
not  properly  sustain  the  viscera,  they  fall  upon  the  fundus  uteri, 
and  tend  to  produce  and  keep  up  anterior  obliquity. 

No  one  can  deny  that  by  a  well-fitting  abdominal  supporter,  tone 
is  given  to  the  lax  walls,  and  that  the  intestines,  not  the  uterus, 
are  sustained.  I  have  already  stated  that  many  are  prejudiced 
against  this  means,  and  decry  it  as  absolutely  injurious;  but  I  see 
it  too  plainly  and  certainly  productive  of  good  results  in  daily 
practice  to  admit  of  any  doubt  in  my  mind  concerning  it.  Dr.  J. 
C.  Nott  offered  a  very  plausible  explanation  of  the  fact  that  in 
some  women  benefit  follows  the  use  of  abdominal  supporters,  while 
in  others,  absolute  injury  results  from  their  employment.  "If  the 
patient  be  emaciated," said  he,  "and  the  aUdominal  walls  retracted 
or  even  flattened,  tlie  supporter  will  depress  and  not  sustain  the 
uterus.  On  the  other  hand,  if  the  woman  be  corpulent,  the  greatest 
support  will  be  yielded  by  its  application."  I  have  employed  for 
this  purpose  witli  very  great  advantage  an  abdominal  pad  or  truss, 
which  is  at  the  same  time  simple,  inexpensive,  and  efficient.     It 

Fig.  95. 


Abdominal  pad  of  wood  or  cork. 

consists  of  an  ovoid  block  of  cedar,  pine,  or  cork,  five  inches  long, 
by  four  inches  wide.  This  is  convex  upon  the  surface  to  be  placed 
next  the  body,  and  flat  on  the  opposite  side,  and  is  held  in  place 
by  an  elastic  band  or  slender  strip  of  steel  covered  with  leather, 
like  an  ordinary  male  truss.  The  pressure  made  resembles  that  of 
the  hand,  and  as  soon  as  patients  become  accustomed  to  it,  which 
it  should  be  borne  in  mind  may  take  a  little  time,  gives  great 
comfor^. 

Pessaries.— W\\^t  is  desired  of  a  pessary  in  sustaining  the  ante- 
verted  uterus  is  this:  to  make  steady  pressure  on  the  base  of  the 


PESSARIES.  367 

bladder  above  tlie  cervico-corporeal  junction,  to  supplement  the 
vesico-uterine  ligaments,  and  at  the  same  time  not  to  injure  the 
vagina  by  excessive  pressure  at  this  point.  It  is  by  no  means 
easy  to  make  an  instrument  answer  these  requirements ;  it  may 
either  keep  the  uterus  in  place  at  the  expense  of  a  degree  of  force, 
which  will  create  a  solution  of  continuity  in  the  vagina,  or  it  may, 
when  possessed  of  too  little  power,  allow  the  fundus  in  spite  of  it 
to  fall  forwards.  The  use  of  pessaries  for  this  displacement  requires 
a  vast  deal  more  skill,  mechanical  ingenuity,  and  patience  than  is 
necessary  in  those  of  posterior  variety.  Even  with  all  these,  cases 
will  commonly  occur  in  which  the  parts  will  be  injured  by  pres- 
sure; and  without  them  the  means  is  one  which  is  attended  by 
absolute  danger.  In  cases  in  which  pelvic  peritonitis  has  preceded 
the  displacement,  the  danger  is  so  marked  that  treatment  by  pessa- 
ries, either  should  not  be  adopted  at  all,  or,  if  attempted,  should 
be  limited  to  the  most  cautious  trials. 

The  diagnosis  having  been  made,  and  it  having  been  decided 
that  retention  of  the  uterus  in  position  is  not  attended  by  danger 
on  account  of  former  pelvic  peritonitis,  and  that  the  displacement 
results  from  no  condition  removable  by  operation,  the  treatment 
should  be  commenced  in  this  way.  The  intestines  should  be  evacu- 
ated by  a  cathartic,  all  weight  removed  from  the  fundus  by  abdo- 
minal and  skirt  supporters,  and  the  patient  enjoined  to  take  very 
moderate  exercise  and  to  avoid  all  violent  efforts.  Every  night 
and  morning  she  should  use  the  warm  vaginal  douche,  not  only  at 
first,  but  throughout  the  duration  of  treatment,  to  prevent  irritation 
from  it.  Every  second  day,  for  a  week  or  ten  days  before  the  in- 
troduction of  a  pessary,  the  uterine  repositor  should  be  introduced, 
the  uterus  gently  thrown  into  a  state  of  retroversion,  and  main- 
tained in  it  for  two  or  three  minutes  at  a  time.  At  the  end  of 
this  period,  if  the  displacement  is  readily  reducible,  and  it  requires 
no  great  force  to  sustain  the  uterus,  the  anteversion  pessary  repre- 
sented in  Fig.  96  may  be  introduced,  and  the  patient  allowed  to 
walk  about.  Should  it  give  no  pain,  she  may  wear  it  home  even  if 
going  to  a  distance  from  the  practitioner's  residence,  for  she  can 
herself  remove  it  on  the  first  menace  of  injury.  In  three  or 
four  days  the  instrument  should  be  examined.  If  it  have  given 
pain  or  have  left  its  mark  upon  the  vaginal  walls,  it  should  be 
changed  at  once;  if  not,  it  may  be  left  for  a  week;  then  for  two 
weeks;  then  for  a  month;  and  afterwards  for  a  still  longer  time, 
two  months,  for  example,  without  examination.     The  pessary  here 


J68 


ANTEVERSION    OF    THE    UTEEUS. 


advised  is  represented  closed  for  introduction  in  Fig.  96,  and  open 
as  it  should  be  in  the  vagina  in  Fig.  97 ;  the  bow  which  sustains 
the  fundus  is  large  and  smooth,  so  as  not  to  injure  the  vaginal  wall. 
When  the  pessary  is  drawn  upon  by  means  of  its  lower  branch, 


Fig.  96. 


G.TIEMANN-CO. 

Thomas's  auteversion  ]>essary  closed. 


Fijr.  97. 


G.TIEMANN-CO. 

Thomas's  anteversion  pessary  open. 

this  bow  flaps  back  of  itself  against  the  base  of  the  pessary,  and 
thus  the  instrument  is  susceptible  of  removal.  The  possibility  of 
removal  by  the  patient  is  an  important  element  in  an  anteversion 
pessary,  for  she  may  go  away  after  its  introduction  and  suffer  agony 
in  a  few  hours,  and  should  she  be  unable  to  remove  it,  inflamma- 
tion might  result.  Even  if  she  obtain  medical  aid,  it  is  often  very 
difficult  for  a  physician  ignorant  of  the  peculiar  construction  of  one 
of  these  instruments  to  remove  it.  I  never  consent  to  a  patient 
who  is  wearing  one  leaving  my  office  to  go  out  of  the  city  without 
first  making  myself  sure  of  her  ability  to  remove  it  herself.  The 
pessary  here  represented  is  introduced  closed  and  carried  to  and 
just  under  the  cervix,  then  by  the  index-finger  the  anterior  arm  or 
bow  is  thrown  forward;  the  cervix  falls  behind  it;  the  fundus  upon 
it;  and  the  posterior  bow  goes  behind  the  cervix.  It  requires  a 
certain  amount  of  practice  to  use  this  and  all  other  anteversion 
pessaries. 


PESS  ABIES. 


3H9 


One  great  advantage  of  this  instrument  is,  that  it  can  be  readilj 
removed  by  the  patient  herself.  Where  she  can  be  kept  under 
observation  of  the  gynecologist  himself,  being  so  near  as  to  be  able 
to  send  for  him  in  case  of  discomfort,  I  prefer  that  represented 
closed  in  Fig.  98,  and  open  in  Fig.  99. 


Fig.  98. 


Fig.  99. 


Thomas's  anteversioii  pessary  closed  and  open. 


It  is  introduced  closed,  the  patient  lying  upon  the  back.  Then 
the  anterior  bar  A  is  pushed  up  against  the  bladder  by  the  index- 
finger,  so  as  to  lift  the  anteverted  uterus,  and  kept  in  this  posi- 
tion, while  the  finger  is  pushed  down,  made  to  engage  the  limb  B, 
wldch  is  folded  back  upon  the  pessary,  and  it  is  drawn  into  the 
position  shown  in  Fig.  99.  The  limb  b  when  extended  is  under 
the  symphysis  pubis. 

In  removing  it,  tlie  top  of  the  index-finger  pushes  up  the  bar  a, 
and  while  holding  it  thus  elevated,  its  palmar  surface  towards  the 
operator,  the  limb  b  is  folded  back  by  the  dorsal  surface,  the  bar 
A  is  pulled  down,  and  the  instrument  slips  out. 

Another  pessary  which  is  very  useful  in  these  cases  is  that  of 
Dr.  Hitchcock,  of  Kalamazoo.      It  consists  of  an  ordinary  ring 
pessary,  elastic  or  not,  with  an  arch 
arranged  as  shown  in  the  diagram. 

If  the  attending  physician  possess 
onl}^  "kittle  skill  in  the  use  of  pessa- 
ries, or  if  the  uterus  be  replaced 
with  diiKculty,  and  sustaining  it 
appear  to  require  force,  he  had 
better  not  employ  an  internal  pes- 
sary, but  limit  himself  to  one  con- 
necting externally  with  a  band. 
Support  may  be  given  by  such  a 
pessary  in  two  wa^'S  :  by  a  pessarj- 

with  a  stem  arching  over  the  perineum,  or  by  one  passing  out  at 
the  upper  vaginal  commissure,  and  going  over  the  symphysis  and 
24 


Fig.  100. 


Hitchcock's  aiiteversinn  pessary. 


370 


ANTEVERSIOK    OF    THE    UTERUS. 


anterior  abdominal  walls.     A  very  simple  one  of  tlie  former  kind 
is  a  modification  of  Cutter's  retroversion  pessary. 

The  upper  extremity  of  tliis  form  of  Cutter's  pessary  has  a  bulb 
attached  to  it,  and  is  so  bent  forwards  as  to  strike  the  base  of  the 
bladder,  anterior  to  the  cervix.  This  is  introduced  by  the  ja'acti- 
tioner,  and  its  method  of  introduction  and  removal  fully  explained 
to  the  patient.  She  is  instructed  to  remove  it  upon  retiring  every 
night,  and  replace  it  before  rising  in  the  morning.  By  it  the  cer- 
vix is  pulled  forwards,  the  utero-sacral  ligaments  stretched,  a  tole- 
rance of  a  foreign  body  established,  and  a  pouch  or  pocket  created 
anterior  to  the  cervix,  which  will  acconniiodate  in  time  the  ante- 
rior bow  of  the  pessary.  Fig.  97,  if  the  practitioner  desires  to  try  it. 
The  bulb  pessary  with  external  attachment  may  in  any  case  be 
used  as  preparatory  to  an  internal  instrument.  After  the  former 
has  been  used  for  a  month  or  so,  the  latter  will  generally  l)e  appli- 
cable. One  having  experience  with  these  two  instruments  can 
almost  always  tell  without  experimentation  which  will  be  appro- 
priate. If  there  be  a  pouch  anterior  to  the  cervix  when  the  base 
of  the  bladder  is  pressed  up  by  the  finger,  the  internal  pessary  will 
be  tolerated.  If  there  be  none,  and  the  tissue  resist  pressure  by 
the  finger,  it  cannot  be  employed  until  space  has  been  created  l)y 
the  other  instrument. 


Fiir.  102. 


Anteversion  pessary  supporting  uterus. 


Anteversion  pessary  supporting  uterus. 


Fig.  102  represents  similar  support,  being  rendered  by  an  almost 
identical  instrument,  which  passes  out  of  the  vagina  anteriorly. 


PESSARIES. 


371 


Cases  will  occasionally  be  met  with  in  which  the  parts  are  so 
sensitive  that  the  hard  bulb  of  these  pessaries  cannot  be  borne. 
Under  these  circumstances,  they  can  be  with  great  advantage 
replaced  bj^  soft  balls  of  very  fine  sponge,  until  the  reposition  of 
the  uterus  and  removal  of  congestion  which  is  thus  effected  render 
solid  bulbs  tolerable. 

Fig.  103  represents  a  very  ingenious  anteversion  pessary  recom- 
mended by  Dr.  Graily  Hewitt.  I  have  little  experience  with  it, 
but  the  evidence  in  its  favor  is  so  strong  that  it  should  not  be 
omittp-d. 

Fiff.  103. 


Graily  Hewitt's  auteversion  pessary. 


I  would  especially  impress  the  importance  of  not  relying  exclu- 
sively upon  any  one  of  these  pessaries  or  internal  supporters.  Their 
use  should  be  combined  with  external  means  calculated  to  remove 
pressure  from  the  fundus.  By  this  combination  the  happiest  results 
may  be  confidently  anticipated  from  efforts  at  relief  of  this  often 
distressing  accident. 

Before  concluding,  let  me  recapitulate  the  most  important  of  the 
maxims  embodied  in  this  chapter. 

1st.  I^Tever  begin  treating  an  anteverted  uterus  mechanically 
until  satisfied  that  no  periuterine  inflammation  exists ;  that  bad 


372  ANTEVEESION    OF    THE    UTERUS. 

symptoms  present  are  due  to  the  displacement;  and  that  no  con- 
dition susceptible  of  removal  by  medical  or  surgical  means  requires 
earlier  and  more  prominent  attention  than  retention  of  the  uterus 
in  position. 

2d.  Before  using  a  pessary,  act  thoroughly  on  the  intestinal  canal, 
use  Avarm  vaginal  injections  freely,  and  rej^lace  the  uterus  repeatedly 
with  the  repositor,  holding  it  in  retroversion. 

3d,  Do  not  rely  upon  vaginal  support  alone,  but  aid  it  by  avoid- 
ance of  all  pressure  from  above,  and  by  using  an  abdominal  pad. 

4th.  Pessaries  are  of  the  greatest  value  in  treating  ante  version, 
but  require  much  more  skill,  are  attended  by  greater  danger,  and 
are  more  apt  to  need  frequent  alteration  than  when  used  in  poste- 
rior displacements.  There  is  no  comparison  in  the  relative  amount 
of  diiRculty  in  applying  this  means  to  the  two  affections. 

5th.  Never  use  an  anteversion  pessary  which  the  patient  cannot 
remove,  unless  she  keep  within  reach  of  your  aid ;  always  examine 
frequently  to  see  if  injury  is  being  done  to  the  vaginal  walls,  and 
never  let  a  patient  wearing  one  pass  entirely  out  of  observation. 

6th.  If  no  sufficient  pouch  exist  anterior  to  the  cervix  for  the 
accommodation  of  an  internal  pessary,  create  one  by  use  of  the 
external  bulb  pessary. 

At  the  same  time  that  I  speak  so  strongly  of  the  difficulties  sur- 
roundij^g  the  treatment  of  those  cases,  and  so  repeatedly  point  out 
the  dangers  attending  it,  I  must  make  this  statement  for  those  who 
have  been  discouraged  by  repeated  failures.  Were  I  asked  from 
the  treatment  of  what  class  of  uterine  diseases  I  experienced  the 
greatest  satisfaction,  and  felt  that  I  had  accomplished  most  good 
for  my  patients,  I  should  unhesitatingly  reply — anteversion  of  the 
uterus. 

In  many  cases  of  this  displacement,  a  great  deal  of  relief  may  be 
obtained  from  merely  lifting  up  the  displaced  organ  in  the  pelvis 
without  rectifying  the  anterior  displacement,  and  for  one  who  is 
not  familiar  with  the  use  of  anteversion  pessaries,  or  has  not  at  his 
command  facilities  for  procuring  good  instruments,  I  really  think 
that  this,  in  the  commencement  of  treatment,  if  not  throughout  its 
entire  course,  is  the  safer  and  better  plan.  Lifting  the  uterus  may 
be  accomplished  by  the  ordinary  ring  pessary  or  Gariel's  air  pessary, 
and  the  simultaneous  use  of  the  abdominal  pad  of  wood  or  cork. 
If  the  pad  be  used  alone,  and  when  the  fundus  uteri  is  behind  the 
symphysis  pubis,  no  good  will  result  from  it;  but  if  the  uterus  be 
lifted  so  that  the  fundus  becomes  amenable  to  direct  pressure,  the 
benefit  felt  will  be  often  very  great. 


RETROVERSION. 


373 


CHAPTER    XXII. 


RETROVERSION. 


Definition  and  Frequency. — -Iletroversion  consists  in  a  posterior 
inclination  of  the  uterus,  so  that  the  fundus  approaches  the  sacrum 

Fig.  104. 


Retroversion  of  the  uterus. 


and  the  cervix  advances  towards  the  symphysis  pubis.  As  an 
idiopathic  primary  lesion,  it  is  not  common,  but  it  is  frequently 
symptomatic  of  neoplasms,  areolar  hyperplasia,  or  other  states 
which  increase  the  weight  of  the  uterus. 

Predisposing  Causes. — The  predisposing  causes  are  parturition, 
general  muscular  debility,  and  habits  of  indolence  and  inactivity. 

Exciting  Causes. — These  may  be  classified  under  four  heads: 

Influences  increasing  uterine  weight. 
Fibroids ; 
Subinvolution ; 
Areolar  hyperplasia ; 
Pregnancy ; 
Congestion. 


374  RETROVERSION. 

Influences  dragging  the  uterus  out  of  jjlace. 

Adhesions  from  jDelvic  peritonitis  or  periuterine  cel- 
lulitis ; 

Rectoeele ; 

Subinvolution  of  the  vagina; 

Prolapsus  of  posterior  vaginal  wall; 

Retroflexion. 
Influences  forcibly  displacing  the  uterus  by  direct  pressure. 

Severe  suceussion  by  blows  or  falls ; 

Muscular  efforts ; 

Distended  bladder ; 

Tumors  ; 

Tight  bandaging  after  parturition  ; 

Tight  and  heavy  clothing. 

Influences  weakening  uterine  supjyorts. 
Pregnancy ; 

Subinvolution  of  vagina ; 
Rupture  of  perineum ; 
Prolapse  of  vagina. 

Of  all  these  causes  the  two  most  frequent  are  decidedly  prolapse 
of  the  vagina,  from  subinvolution  or  ruptured  perineum  ;  and  areo- 
lar hyperplasia,  the  advanced  stage  of  subinvolution  of  the  uterus. 
All  the  others  mentioned  are  sometimes  met  with,  but,  compared 
with  these,  they  are  insignificant  as  causes. 

As  might  be  presumed  from  the  natural  anterior  obliquity  of 
the  uterus,  anteversion  not  unfrequently  occurs  as  an  idioi:)athic 
lesion,  resulting  from  pressure  of  superincumbent  viscera  forced 
down  upon  the  fundus  by  tight  clothing  or  muscular  efl:brts. 
Retroversion  occurs  in  this  way  less  frequently.  It  generally  de- 
pends upon  some  pathological  state  in  the  uterus  or  its  appendages. 
The  third  class  of  causes  mentioned  as  retroverting  the  organ  by 
direct  pressure,  may  act  through  violent  suceussion  and  induce 
sudden  displacement  with  symptoms  of  most  urgent  character. 
Prolonged  pressure  from  a  distended  bladder  or  from  a  tumor  ante- 
rior to  or  above  the  uterus,  may  likewise  induce  gradual  displace- 
ment. A  little  reflection  will  explain  how  the  management  of 
parturient  women,  by  British  and  American  practitioners  at  least, 
favors  the  occurrence  of  the  accident.  In  the  first  place,  it  must 
be  remembered  that  pregnancy  combines  in  itself  two  of  the  influ- 
ences which  are  productive  of  this  condition,  increase  of  uterine 


VARIETIES.  375 

weight  and  relaxation  of  supports.  It  is  no  exaggeration  to  assert 
that  the  usual  plan  of  management  after  parturition  supplies  one  of 
the  others  which  are  mentioned  above.  The  woman  lying  almost 
constantly  upon  her  back,  the  heavy  fundus  naturally  tends  to 
fall  backwards  into  the  hollow  of  the  sacrum.  Many  nurses 
insist  upon  this  position  and  often  for  days  refuse  the  patient  the 
privilege  of  lying  upon  the  side.  But  this  is  not  all,  many  a 
nurse's  reputation  among  ladies  rests  upon  her  capacity  for  "  pre- 
serving the  figure"  by  tight  bandaging.  A  powerful  woman  m' ill 
often  expend  her  wliole  force  in  making  the  bandage  as  tight  as 
possible  to  accomplish  this  purpose.  'No  one  who  has  watched 
the  process  can  doubt  its  influence  in  displacing  the  uterus  by 
direct  pressure.  There  is  no  practice  connected  with  the  lying-in 
room,  to  which  so  much  of  almost  superstition  attaches  as  to  the 
use  of  the  obstetric  bandage  for  preservation  of  the  figure  and 
prevention  of  hemorrhage.  This  is  a  repetition  of  what  I  have 
elsewhere  stated,  but  the  importance  of  the  subject  in  my  mind, 
must  be  my  excuse  for  dwelling  upon  it  here. 

If  involution  have  gone  on  tardily  and  imperfectly,  the  woman  is 
still  more  prone  to  having  the  uterus  forced  backwards.  The  round 
ligaments,  which  are  composed  of  muscular  structure  similar  to  that 
of  the  uterus,  are  important  agents  in  preventing  this.  It  is  highly 
probable  that  an  arrest  of  retrograde  metamorphosis  affecting  the 
uterus  may  likewise  affect  them,  and  leave  them  longer  and  less 
powerful  than  natural.  "  Hypertrophy  of  the  two  (round)  liga- 
ments," says  Scanzoni,^  "  constantly  accompanies  a  normal  preg- 
nancy :  while,  as  we  have  ourselves  had  an  opportunity  to  determine, 
in  the  case  of  a  bicorned  uterus,  biparted,  or  bilocular,  the  liga- 
ment corresponding  to  the  side  on  which  was  the  pregnancy,  was 
alone  hypertrophied.  .  .  .  We  remember  many  cases  of  women 
who  have  died  after  metritis  or  puerperal  peritonitis,  with  whom 
one  or  both  of  the  round  ligaments  were  notably  hypertrophied, 
and  presented  a  lively  red  color,  with  a  serous  infiltration." 

Not  only  as  a  result  of  pregnancy  do  these  ligaments  develop  a 
condition  which  renders  them  prone  to  yield  to  traction  from  an 
enlarged  uterus — Boivin  and  Dug^s  have  observed  hypertrophy  in 
them,  with  dilatation  of  their  vessels  from  chronic  engorgement, 
fibroids,  and  even  from  ovarian  tumors. 

Varieties  of  Retroversion. — It  may  exist  in  slight  degree,  the 
uterine  axis  inclining  so  as  to  make  with  that  of  the  superior 

'  Scanzoni,  op.  cit.,  p.  358. 


37t> 


RETROVERSION. 


Strait  an  angle  of  45°  ;  or  it  may  incline  to  90°,  thus  lying  across 
the  pelvis ;  or  the  cervix  may  be  thrown  up  and  the  fundus 
descend  so  as  to  form  an  angle  of  135°.  These  varieties  constitute 
the  first,  second,  and  third  degrees  of  retroversion. 

Fig.  105. 


The  degrees  of  retroversion. 

Symptoms. — Although  retroversion  is  often  itself  a  symptom,  it 
creates  disturbances  which  without  its  existence  would  not  have 
shown  themselves.  For  this  reason  it  is  difficult  to  determine 
what  elements  of  the  case  are  due  to  it,  and  what  depend  upon  the 
disorder  producing  it.  It  may  exist  without  adding  anything  to 
the  catalogue  of  symptoms,  as  proved  b}^  the  fact  that  its  removal 
accomplishes  nothing  in  the  way  of  relief;  but  usually  it  creates 
tenesmus  of  bladder  and  rectum,  together  with  congestion  in  the 
lining  membrane  of  these  viscera;  fixed,  gnawing  pain  in  the  back: 
discomfort  in  locomotion ;  and  pain  in  defecation.  These,  how- 
ever, are  not  sufficient  for  diagnosis,  and  often  do  not  excite  sus- 
picion of  its  existence.  It  is  generally  discovered  by  vaginal  touch. 
These  remarks  do  not  apply  to  sudden  retroversion,  the  result  of 
succussion,  in  which  variety  the  symptoms  are  marked  and  severe. 
The  patient  falls  to  the  ground  and  is  unable  to  rise,  experiences 
the  severest  pelvic  pain,  suffers  from  suppression  of  urine  and  feces, 
and  is  often  in  such  agony  tliat  the  face  is  bathed  witli  perspira- 
tion and  the  pulse  becomes  weak  and  fluttering. 


TREATMENT.  377 

Physical  Signs. — The  linger  being  introduced  into  the  vagina 
discovers  an  absence  of  the  cervix  from  its  usual  place,  and  upon 
further  investigation  finds  it  near  the  symphysis  pubis.  Upon 
passing  the  finger  backwards  to  the  sacrum  it  meets  a  resisting 
ridge  which  ends  in  a  hard,  round  mass,  resting  upon  the  rectum. 
The  size,  rotundity,  and  distinctness  of  this  will  depend  upon  the 
degree  of  the  displacement.  In  the  first  degree  the  resisting  line 
but  no  tumor  will  be  felt;  in  the  second,  a  slightly  rounded  mass; 
and  in  the  third,  the  fundus  with  its  characteristic  form  will  be 
perceived.  All  doubt  as  to  the  nature  of  the  mass  thus  felt  may 
be  removed  hj  rectal  touch,  the  uterine  probe,  and  conjoined 
manipulation. 

Differentiation. — This  affection  may  be  confounded  with  a  fibrous 
tumor  on  the  posterior  uterine  wall,  and  the  results  of  pelvic 
peritonitis  or  cellulitis.  A  little  attention  to  the  direction  of  the 
uterine  axis  as  demonstrated  by  the  j)osition  of  the  cervix,  the  use 
of  conjoined  manipulation,  and  the  passage  of  the  uterine  probe 
will  usually  settle  the  question  at  once.  Unless  the  case  be  very 
clear  it  is  unsafe  to  rely  upon  vaginal  touch  for  a  diagnosis.  Con- 
joined manipulation  and  the  uterine  probe  should  be  brought  to 
our  aid. 

Prognosis. — There  are  three  conditions  which  render  the  prog- 
nosis of  this  condition  unfavorable:  where  the  uterus  is  bound 
down  by  strong  adhesions ;  where  the  organ  contains  in  its  paren- 
chyma a  fibrous  tumor ;  and  where  the  vagina  is  attached  to  the 
cervix  so  near  the  external  os  that  no  pessary  can  rest  posterior  to 
the  cervix  to  sustain  the  uterus  after  it  is  replaced.  This  form  of 
utero- vaginal  junction  is  important  as  giving  ground  for  a  very 
grave  prognosis  as  to  the  cure  of  all  anterior  and  posterior  displace- 
ments. 

Results. — This  displacement  may  produce  the  following  dis- 
orders : 

Congestion ; 
Areolar  hyperplasia ; 
Dysmenorrhoea ; 
Sterility ; 
Cystitis ; 
Rectitis. 

Treatment  of  Posterior  Displacements  in  which  Version  predomi- 
nates.— The  first  indication  is  to  restore  the  uterus  to  its  place,  the 
second  to  prevent  its  again  becoming  displaced. 


378  EETROVERSION. 

Methods  of  Bedudion. — In  an  ordinary  case  in  whicli  the  uterus  is 
not  firmly  lield  in  retroversion  by  the  surrounding  parts,  the  patient 
should  be  placed  on  the  left  side  as  for  an  ordinary  examination 
with  Sims's  speculum.  The  operator  then  lubricating  the  index 
and  middle  finger  of  the  right  hand  introduces  them  to  the  fundus, 
he  standing  at  the  patient's  back,  and  facing  her  head,  the  palmar 
surfaces  of  the  fingers  being  directed  to  the  rectum.  The  uterus  is 
lifted  upon  the  inner  surface  of  the  fingers  until  it  becomes  erect, 
then  their  dorsal  surfaces,  which  will  roallj'  be  the  backs  of  the 
nails,  are  made  to  push  the  organ  over  into  normal  position.  I 
would  uro-e  the  trial  of  this  method  exactlv  as  here  described,  and 
will  answer  for  its  efliciency. 

But  sometimes  the  uterus  is  irreducible  by  any  but  the  most 
powerful  methods.  In  such  a  case  the  bladder  and  rectum  having 
been  evacuated,  and  the  clothing  loosened,  the  patient  is  made  to 
kneel  upon  a  hard  surface,  and  to  place  the  sternum  as  closely  as 
possible  in  contact  with  the  plane  which  sup[)orts  her.  The  prac- 
titioner then  lubricating  two  fingers  of  the  right  hand  carries  them 
into  the  vagina  and  against  the  fundus.  He  then  directs  the 
patient  to  fill  the  chest  with  air,  and  expel  it  completely.  As  she 
does  so,  he  forcibly  elevates  the  fundus  and  restores  it  to  its  place. 
Should  this  plan  fail,  the  buttocks  should  be  still  more  elevated  by 
placing  cushions  under  the  knees,  and  the  attemj^t  repeated  with 
two  fingers  in  the  rectum  instead  of  in  the  vagina. 

Should  these  powerful,  and  usually  efficient  methods,  fail,  I  would 
strongly  urge  against  efforts  being  made  by  introduction  of  instru- 
ments for  restitution  into  the  uterus.  If  they  exert  less  force,  they 
will  not  be  eflfectual;  if  more,  they  may  penetrate  the  uterus  and 
create  peritonitis.  Besides,  in  a  case  resisting  the  j^lan  detailed, 
there  will  probably  be  found  to  be  adliesions  as  the  source  of  the 
difficulty.  Under  these  circumstances,  Ivuchenmeister'  has,  from 
extended  experience,  advised  the  introduction  of  the  colpeurynt;er, 
filled  with  water  every  day,  for  as  long  a  time  as  the  patient  can 
bear  it.  Steady  hydrostatic  pressure  often  in  this  way  accomplishes 
safely  what  sudden  force  would  do  with  danger  to  the  patient. 

In  cases  requiring  the  application  of  much  less  force,  Sims's  re- 
positor  is  an  excellent  instrument  for  the  purpose,  and  should  be 
employed.  This  instrument,  which  is  represented  by  Fig.  106, 
consists   of  a  short   metal   sound,   terminating   in   a   ball.     The 

•  Am.  Journ.  Med.  Sci.,  July,  1870,  p.  275. 


METHODS    OF    RETENTIOX.  379 

ball  is  clasped  by  a  straight  shaft,  moves  upon  a  pivot  runniug 
through  its  centre,  and  is  perforated  by  seven  holes.  Through  the 
shaft  runs  a  rod  which  is  projected  by  a  concealed  spring,  that  is 
o;overned  by  the  finger  passed  through  the  ring.  The  ball  can 
be  made  to  revolve  so  that  the  sound  describes  a  half  circle,  by 
withdrawing  the  stop-rod  which  runs  through  the  shaft,  and 
depressing  the  instrument. 

Fig.  106. 


Sims's  uterine  repositor. 

An  instrument  which  is  more  commonly  employed  is  the  uterine 
sound.  This  beins;  introduced  to  the  fundus  should  be  made  to 
elevate  and  rotate  the  uterus  in  this  manner :  the  operator  holding 
the  handle  in  his  left  hand  should  press  upon  the  staft"  near  its 
middle  by  the  tips  of  the  fingers  of  the  right  hand,  and  thus, 
making  of  the  left  hand  a  fulcrum,  and  of  the  sound  a  lever,  push 
the  handle  gently  and  steadily  back  to  the  perineum.  This  move- 
ment will  lift  the  uterus,  and  partially  restore  it.  ]!^ow  very 
gently  making  the  tip  of  the  sound  revolve,  he  by  doing  so  carries 
the  uterus  into  a  condition  of  anteversion. 

In  the  majority  of  instances  reposition  is  perfectly  practicable 
by  conjoined  manipulation  or  rectal  taxis,  or  by  means  of  a  sponge 
fixed  in  a  sponge-holder  and  pressed  into  the  fornix  vaginae. 

Good  results  will  often  attend  carrying  one  sponge  staff  up  the 
rectum  and  another  up  the  vagina,  so  as  to  make  pressure  upon  the 
displaced  fundus,  after  the  plan  adopted  by  Dr.  Bond,  of  Philadel- 
phia, in  his  ingenious  repositor,  which  is  represented  in  Prof.  Meigs's 
work  on  Midwifery.  In  replacing  a  uterus  in  this  or  any  other 
malposition,  the  operator  should  never  forget  that  inflammatory 
action  may  have  caused  an  effusion  of  lymph  around  it  which 
resists  its  removal,  and  that  if  these  adhesions  be  violently  ruptured, 
cellulitis  or  peritonitis  may  result. 

Methods  of  Retention. — Having  restored  the  organ  to  its  normal 
place,  the  question  which  should  next  suggest  itself  is  not  how 
to  retain  it  there,  hut  whether  such  retention  is  advisable,  practi- 
cable, and  void  of  danger ;  whether  the  patient  is  suffering  from 
symptoms  especially  referable  to  the  displacement,  or  this  is  merely 


380  KETEOVEESION. 

a  siirn  of  existino-  disease,  which  makes  the  mechanical  treatment 
of  displacement  hazardous.  Under  such  circumstances,  where,  for 
example,  pelvic  peritonitis  is  present,  local  treatment  should  be 
dispensed  with.  As  a  rule,  however,  even  if  uterine  disease  of 
subacute  or  chronic  character  exist,  and  the  displacement  be 
regarded  as  aggravating  it,  and  adding  to  the  discomfort  of  the 
patient,  an  eftbrt  should  be  made  to  overcome  it  by  local  means. 
Our  resources  for  accomplishing  this  are  the  following: 

Abdominal  decubitus ; 

The  tampon ; 

The  abdominal  supporter ; 

Pessaries ; 

Perineorrhaphy ; 

Elytrorrhaphy. 

For  the  purpose  of  fully  exhibiting  the  method  of  treating  a 
chronic  case  of  this  disorder,  I  will  suj)pose  that  we  are  dealing 
with  one  of  rebellious  character,  in  which  there  is  considerable 
tenderness  about  the  uterus,  so  that  it  will  not  tolerate  the  pressure 
of  a  pessary  sufficiently  ^wwerful  to  keep  it  in  Jiosition.  A  prepa- 
ratory course  of  treatment  is  necessary,  as  in  the  case  of  anteversion, 
before  resorting  to  a  pessary.  The  bowels  should  be  evacuated ;  the 
vagina  syringed  with  warm  water  night  and  morning;  all  weight 
taken  from  the  abdomen  by  a  skirt  supporter,  an  abdominal  sup- 
porter, and  avoidance  of  all  muscular  efibrts ;  and  the  uterus  be 
replaced  and  held  in  the  condition  of  complete  anteversion  for  two 
or  three  minutes,  once  in  every  forty-eight  hours,  for  a  week  or 
more.  After  a  week  has  been  allotted  to  these  eftbrts  at  preparation 
for  the  permanent  support  of  the  displaced  organ,  a  tampon  of 
carbolized  cotton,  or  a  sponge  saturated  with  glycerine,  should  be 
applied  in  the  following  way :  the  uterus  being  held  in  a  state  of 
complete  anteversion  by  means  of  the  uterine  repositor  or  sound, 
a  roll  of  cotton  about  the  size  of  a  small  hen's  egg,  or  an  egg- 
sponge  moistened  with  carbolized  glycerine,  should  be  carefully 
pushed  as  far  as  it  will  go  into  the  fornix  vaginae.  Then,  the 
sound  being  removed,  a  large  roll  of  cotton  should  be  placed  below 
the  cervix  and  a  little  anterior  to  it,  (not  behind  it,  as  the  first 
one  was,)  but  so  arranged  as  to  lift  this  part  up  into  the  hollow  of 
the  sacrum  against  the  roll,  which  has  now  become  invisible,  in 
the  fornix  vaginee.  The  subcervical  tampon  not  only  pushes  back 
the  cervix,  which  was  before  its  introduction  near  the  symphysis 


PESSAEIES.  381 

pubis,  but  it  still  further  elevates  the  supra-cervical  roll,  which 
thus   pushes   the    fundus   farther   and    farther   upwards   until   it 
topples  over  forwards  by  its  own  weiglit, 
uninterfered  with  as  it  is  by  pressure  from  ^^S-  107. 

above,  and  aided  bj  the  abdominal  decu- 
bitus which  should  be  observed  by  the 
patient.  The  accompanying  diagram  will 
explain  the  action  of  these  two  portions 
of  the  tampon  tvhen  -properly  applied.  If, 
instead  of  being  thus  applied,  the  ordi- 
nary tampon  be  emijloyed,  and  the  lower 
portion  of  the  vagina  be  filled,  nothing  is 
accomplished  but  elevation  of  the  retro- 
verted  organ.     What  we  desire  to  produce 

is  anteversion.  After  the  introduction  of  the  subcervical  pad  as 
shown  in  tlie  figure,  the  vagina  is  filled  with  cotton  to  keep  this  in 
place,  as  well  as  to  elevate  the  whole  uterus,  and  bring  gravitation 
to  our  aid  in  throwing  the  body  forwards.  I  do  not  look  u])on  the 
abd(nninal  decubitus  as  a  valuable  resource  in  the  treatment  of 
retroversion,  but  merely  as  an  adjuvant  to  other  means,  which 
directly  straighten  the  axis  of  the  uterus.  Lift  the  retroverted 
organ,  and  it  has  a  certain  degree  of  efiicacy,  as  an  adjuvant,  which 
it  does  not  possess  while  the  displacement  is  in  existence.  The 
tampon  may  be  retained  for  forty-eight  hours  without  inconveni- 
ence, if  the  material  of  which  it  is  comj)osed  be  properly  prepared 
by  means  of  antiseptic  drugs.  This  is  of  so  much  importance  that 
I  shall  here  describe  the  manner  in  which  cotton  should  be  prepared. 

A  large  mass  of  fine  cotton  should  be  kept  immersed  for  three 
or  four  days  in  a  saturated  solution  of  bicarbonate  of  soda,  and 
then  taken  out  and  thoroughly  dried  in  the  sun.  "When  a  wad  of 
this  is  to  be  used,  it  should  be  saturated  in  a  solution  of  half  a 
drachm  of  crystals  of  carbolic  acid  in  one  quart  of  water,  then 
squeezed,  dipped  in  glycerine,  slightly  squeezed  again,  and  applied. 
Thus  prepared,  the  tampon  is  not  only  antiseptic  in  its  properties, 
it  proves  an  excellent  method  for  treating  chronic  and  even  sub- 
acute vaginitis,  while  it  is  decidedly  beneficial  in  its  effects  upon 
the  so-called  ulcer  of  the  cervix. 

During  the  use  of  this  means  the  patient  may  go  about  and 
attend  to  her  usual  avocations,  although,  if  it  l)e  convenient,  it  is 
better  to  confine  her  to  the  abdominal  decubitus. 

Should  the  residence  of  the  patient  be  out  of  the  city,  or  licj- 
pecuniary  condition  render  it  impossible  for  her  to  be  treated  as 


382  RETROVEESION. 

here  advised,  tlie  plan  may  be  imitated  by  one  which  is  very 
effectual,  and  much  less  troublesome  to  patient  and  physician. 
The  uterus  being  thrown  into  anteversion  by  the  repositor,  or  tAVO 
fingers  introduced  into  the  fornix,  while  the  patient  is  in  the  left 
lateral  position,  a  sponge  pessary,  which  consists  in  the  attachment 
of  a  soft  egg-sponge,  instead  of  a  bulb,  to  the  stem  of  Cutter's 
pessary.  Fig.  Ill,  should  be  left  in  position.  The  sponge  fits  in 
tlie  vaginal  cul-de-sac,  is  steadily  pushed  U})ward8  against  the 
uterus  by  the  elastic  dorsal  strap,  and  forcibly,  but  gently,  keeps 
the  organ  in  normal  position.  For  such  cases  as  those  just  indi- 
cated, and  for  others  in  which  the  retroversion  is  so  obstinate 
that  it  falls  backwards  in  spite  of  a  pessary  passed  entirely  into 
the  vagina,  this  constitutes  a  means  of  such  great  value,  that  I 
urge  its  trial  in  all  diflicult  cases.  By  it  I  have  controlled  many 
cases  which  had  resisted  all  other  plans  of  mechanical  treatment, 
and  feel  assured  that  it  will  not  fail  to  produce  in  the  hands  of 
others  as  good  results  as  it  has  yielded  me.  Of  course,  it  is  only  a 
temporary  and  prejiaratory  means,  I'or  sponge  is,  at  all  times,  an 
objectionable  substance  to  leave  in  the  vagina.  It  should,  in  this 
case,  be  removed,  washed,  and  replaced  once  in  every  twelve  hours. 
For  this  same  temporary  and  preparatory  end,  Ilurd's  or  Hoff- 
man's pessary  may  be  introduced,  for  the  purpose  of  gently  elevat- 
ing the  fundus  l)y  an  obtuse  body  introduced 
Fig-  108.  into  the  vaginal  cul-de-sac.     These  instru- 

ments should  be  watched,  for  they  sometimes 
incarcerate  the  neck.  They  should  likewise 
be  ke[)t  very  clean  by  co})ious  and  frequent 
vaginal  douching. 

After  the  methods  thus  far  described  have 

H^manTrnflated^oft      ^^^^^  purBued  for  a  fortnight  or  three  weeks, 

rubber  pessary.  even  the  worst  cascs  will  generally  tolerate  a 

well-adjusted  permanent  pessary;  but  where 

this  tolerance  is  not  developed,  the  medicated  tampon  or  sponge 

pessary  should  be  continued  until  it  is  so. 

One  important  point  in  connection  with  this  method  of  replacing 
the  uterus  is  this.  The  round  ligaments  are  attached  to  the  horns 
of  the  organ,  and  at  the  vulva.  If  the  rctroverted  or  retroflexed 
uterus  be  left  in  malposition  and  simply  pushed  up,  the  ligaments 
will  inevitably  increase  and  insure  the  continuance  of  the  displace- 
ment. If,  on  the  other  hand,  the  body  be  thrown  forwards  and 
kept  in  anterior  position  until  the  organ  be  lifted,  the  round  liga- 
ments becoming  tense,  tend  to  act  remedially  on  posterior  devi- 


PESSARIES.  383 

ations.  A  little  thought  will  convince  the  reader  of  the  truth  of 
this  statement.  It  is  upon  this  action  of  the  round  ligaments  that 
I  in  part  depend  for  the  benefit  of  the  plan  which  I  am  describing. 

It  may  be  asked  whether  I  propose  to  treat  all  cases  of  retro- 
version in  this  manner  in  the  beginning.  No;  I  do  not.  I  pre- 
faced these  remarks  upon  preparatory  treatment  by  stating  that  I 
A  supposed  the  practitioner  to  be  dealing  with  an  aggravated  case 
and  one  intolerant  of  support.  Most  cases  will  at  once  admit  of 
the  use  of  a  retroversion  pessary,  and  require  no  preparatory  treat- 
ment. There  are,  however,  many  others  which  do  require  it  and 
in  which  immediate  resort  to  artificial  support  proves  injudicious; 
even  dangerous.  Some  may  suppose  that  a  great  deal  of  time 
must  be  consumed  by  this  prej^aratory  treatment  which  is  not 
absolutely  necessary  for  the  relief  of  the  case.  If  preparatory  treat- 
ment be  not  necessary,  it  should  not  be  resorted  to;  if  it  be  neces- 
sary, time  will  be  gained  and  not  lost  by  its  adoption.  At  least 
let  me  urge  this  advice:  when  the  most  carefully  adjusted  pessaries 
create  discomfort,  let  a  month  be  devoted  to  the  preparatory  treat- 
ment which  I  have  described,  and  at  its  end  let  pessaries  be  again 
tried.  Many  cases  will  then  be  found  to  yield  to  mechanical  treat- 
ment which  were  rebellious  to  it  before,  and  more  certainly  so  if  the 
means  recommended  for  removing  pressure  upon  the  fundus  from 
above  be  faithfully  put  in  practice.  Some  of  the  most  gratifying 
results  of  gynecology  will  be  found  to  arise  from  a  cautious,  patient, 
and  philosophical  treatment  of  these  cases.  But  let  no  one  suppose 
that  a  careless  fulfilment  of  the  directions  given  is  likely  to  perform 
all  this.  If  the  plan  which  I  am  urging  be  used  unintelligently  and 
roughly,  it  will  do  harm  and  not  good,  and  result  in  annoyance  and 
not  comfort  to  the  patient. 

It  has  now  been  decided,  we  will  suppose,  to  try  the  efliects  of  a 
retroversion  pessary.  Which  of  the  many  varieties  at  our  com- 
mand shall  be  selected?  I  have  but  three  to  advise,  although  I 
shall  mention  a  larger  number.  It  will  be  observed  that  I  very 
decidedly  prefer  a  modification  of  Prof.  Hodge's  pessary  to  the 
original  instrument.  While  doing  this  I  do  not  wish  to  overlook 
the  fact  that  to  this  practitioner  gynecology  is  more  indebted  for 
a  scientific  plan  for  supporting  the  uterus  affected  l)y  posterior 
displacement,  than  to  any  otlier  who  has  given  his  efforts  to  the 
subject.  All  the  varieties  of  lever  pessary  now  employed  are  modi- 
fications of  his  original  and  most  valuable  idea,  and  act  upon  the 
principle  whicli  it  developed. 

The   rule   which   has   been   observed   with   reference   to   other 


884 


EETROVERSION. 


Fig.  109. 


mechanical  inventions  has  not,  however,  been  wanting  here ;  sub- 
sequent labors  based  upon  the  original  thought  have  greatly  im- 
proved its  application.  Thus,  there  are 
varieties  of  retroversion  pessaries  whicli 
are  as  far  superior  to  Prof.  Hodge's  model 
as  there  are  varieties  of  repeating  fire- 
arms superior  to  Colt's  original  concep- 
tion. 

Until  four  years  ago  I  very  commonly 
emjiloyed  Hodge's  pessary,  and  always 
kept  a  large  supply  on  hand.  I  used 
this  as  a  rule  in  retroversion,  and  other 
varieties  only  exceptionally.  About  that 
time  my  attention  was  drawn  by  my 
friend,  the  late  Dr.  James  L.  Brown,  to  the  great  sujjeriority  of  tlie 
modification  of  this  instrument  by  Dr.  Albert  Smith,  of  Philadel- 
phia, and  at  his  solicitation  I  made  trial  of  it.  Since  that  time  I 
have  done,  what  many  of  my  acquaintances  who  have  tried  it  have 
also  done ;  I  liave  employed  it  almost  universally  where  formerly  I 
used  Hodge's  instrument.  Tlie  Albert  Smitli  i)essary  is  shown  in 
Fig.  110.  It  is  longer,  less  expanded,  and  much  more  pointed  at 
the  pubic  extremity  than  Hodge's.  While  the  latter  rests  against 
the  rami  of  the  pubes,  the  former  rests  between  them. 


Hodge's  closed  lever  pessary. 


Fijr.  110. 


Albert  Smith's  pessary. 

This  pessary  is  that  which  I  usually  try  first  in  retroversion. 
In  a  certain  number  of  cases  it  fails  for  the  following  reasons. 
The  displaced  body  is  so  heavy  and  presses  so  forcibly  downwards 
that  a  pessary  of  ordinary  size  is  driven  out  of  the  vagina,  or  so 
low  down  as  to  allow  descent  of  the  fundus.  This  might  be 
obviated  by  employing  an  instrument  of  large  size  and  great  expan- 
sion of  limbs,  but  this  the  vagina  cannot  tolerate.  It  sets  up 
ulceration  and  creates  pain  from  pressure  and  distention.    In  other 


PESSAKIES, 


385 


words;  without  a  very  firm  base  the  uterus  forces  out  the  instru- 
ment ;  with  a  sufficiently  firm  base  to  resist  this,  ulceration  from 
excessive  pressure  results. 

In  some  cases  so  very  great  is  the  pressure  exerted  by  the  dis- 
placed uterus,  that  no  purely  internal  support  will  answer  the 
purpose  of  sustaining  it,  for  the  point  against  which  either  the 
[)ubic  or  uterine  extremity  of  the  instrument  rests  will,  in  spite 
of  every  precaution,  become  ulcerated.  Under  these  circumstances 
I  have  obtained  the  most  gratifj'ing  results  from  the  use  of  a 
modification  of  Cutter's  retroversion  pessary,  intended  to  obviate  a 
difficulty  which  I  found  attend  that  excellent  instrument,  that  of 
cuttino-  throuarh  the  vao-ina.  If  no  o-reat  amount  of  pressure  is  to  be 
borne,  Cutter's  pessary  answers  very  well  for  this  purpose ;  if  great 
pressure  is  to  be  borne,  the  point  of  his  instrument  endangers  the 
tissues.  For  this  reason  I  have  affixed  to  the  top  of  Cutter's  pessary 
bulbs  of  difterent  size — some  as  large  as  a  hickory  nut — for  the 
object  is  not  only  to  prevent  cutting  of  the  vagina,  but  to  place 
behind  the  displaced  fundus  a  mass  which  will  make  it  fall  forwards 
by  displacement^  and  not  by  pressure.  My  alteration  of  this  instru- 
ment is  insignificant ;  the  entire  credit  of  it  belongs  to  Dr.  Cutter, 
to  whom  I  personally  feel  indebted  for  afibrding  me  so  valuable 


Fi£r.  111. 


Fig.  112. 


Modification  of  Cutter's  pessary. 


Cutter's  pessary. 


and  simple  a  method  for  meeting  the  difficulties  of  aggravated 
retroversion.  Had  I  space,  I  could  cite  a  number  of  very  bad 
cases  of  this  difficulty,  which  had  for  years  resisted  treatment 
by  ordinary  pessaries,  and  wdiich  have  readily  yielded  to  the  use 
25 


386 


RETROVERSION. 


of  the  bulb  pessary  exhibited  in  Fig.  111.  The  inferior  extre- 
mity of  this  pessary  arches  backwards  over  the  coccyx,  and 
attaches  to  an  elastic  cord  which  passes  upwards  over  the  sacrum 
to  a  2;irdle  around  the  waist.  .  It  is  a  painless  and  efficient  method 
of  2;ivino:  support,  and  will  gain  a  high  reputation  on  account  of 
these  qualities  in  posterior  displacements.  The  class  of  cases  to 
which  it  is  especially  applicable,  is  that  in  which  the  displacement 
is  due  to  prolapse  of  the  posterior  vaginal  wall  from  rupture  of 
the  perineum  or  other  cause.  When  employed  for  posterior  dis- 
placements, the  upper  extremity  of  the  instrument  simply  lies  in 
the  fornix  vaginee,  the  cervix  of  course  not  entering  the  fenestra. 

This  instrument  should  be  removed  every  night  and  reinserted 
every  morning.  It  may  be  said  that  this  will  prove  difficult  of 
accomplishment  for  the  patient.  Out  of  several  liundred  cases  in 
which  I  have  used  it,  I  have  never  found  an  instance  of  failure  in 
this  respect.  The  patient  will  very  often  become  disaflected 
towards  the  instrument  from  its  chafing  the  perineum.  By  a  little 
patience,  covering  the  points  which  rub  with  greased  lint,  and 
leaving  the  pessary  out  until  the  irritated  part  be  healed,  the  feeling 
will  soon  pass  away. 

These  are  the  instruments  which  I  recommend  for  retroversion 
of  the  uterus.      There  are  other  varieties,  however,  which  often 

answer  an  excellent  purpose.     To 
Fig.  113.  Hewitt's  pessary  there  is  no  objec- 

tion, if  the  weight  to  be  sustained 
be  slight.  If  it  be  at  all  great, 
this  instrument  is  utterly  inade- 
quate to  cope  with  it.  It  is  not 
simply  inefficient;  it  is  in  such 
cases  a  dangerous  instrument,  for 
resting  against  the  soft  i)arts 
covering  the  symphj^sis  pubis  it 
Hewitt's  pessary.  niay,  as  I  liave  seen  it  do,  cut  di- 

rectly through. 
In  cases  where  very  little  pressure  is  exerted  by  the  retroverted 
body,  and  where  retroversion  is  accompanied  by  marked  descent, 
an  ordinary  elastic  ring,  like  that  of  Prof.  Meigs,  will  often  be 
found  very  serviceable.  Messrs.  Tiemann  &  Co.  have  recently 
modified  ^leigs's  ring  pessary  by  making  it  of  a  very  delicate  ring 
of  whalebone  covered  by  India-rubber.  It  is  so  elastic  as  to  assume 
any  shape  required  by  the  pelvis,  and  answers  an  excellent  purpose 
in  patients  who  are  so  sensitive  as  not  to  be  able  to  bear  a  less 


PESSARIES.  387 

pliable  support.  To  one  unaccustomed  to  the  use  of  pessaries  the 
simplicity  and  elasticity  of  this  instrument  will  prove  very  seduc- 
tive, and  lead  to  a  belief  in  its  perfect  harmlessness.  Such  a 
reliance  will  prove  utterly  delusive.  Even  the  most  elastic  will 
often  cut  through  the  vaginal  walls  when  the  instrument  is  a  little 
too  large.  It  is  more  liable  to  produce  this  result  than  any  other 
variety  of  pessary. 

All  of  the  instruments  thus  far  mentioned  act  by  pushing  the 
fundus  up,  and  thus  carrying  the  cervix  back  into  the  upper 
part  of  the  vagina.  Spiegelberg  has  advocated  the  method  of  not 
only  doing  this,  but  at  the  same  time  by  engaging  the  cervix  in  a 
ring  at  the  extremity  of  a  retroversion  pessary,  forcing  it  backwards 
and  upwards.  In  some  cases  this  will  be  found  to  be  an  excellent 
means.  By  merely  arranging  a  cross  bar  near  the  upper  part  of 
one  of  the  retroversion  pessaries  just  mentioned,  this  may  be 
accomplished. 

If  the  posterior  vaginal  wall  need  support,  which  it  has  lost  from 
rupture  of  the  perineum,  the  operation  of  perineorrhaphy  may  be 
of  great  service,  by  preventing  prolapse  of  the 
posterior  wall  of  tlie  vagina,  and  dragging  upon  Fig.  114. 

the  uterus.  Should  it  appear  that  this  procedure 
will  not  be  sufficient,  posterior  elytrorrhaphy 
may  be  resorted  to  with  the  best  hopes  of  cure. 

After  the  introduction  of  every  pessary,  the 
position  of  the  uterine  body  should  be  at  once 
examined,  either  by  the  probe,  by  conjoined 
manipulation,  or  by  both,  to  ascertain  whether  Meigs's  ring  pessary. 
it  be  efficient  or  not.  If  it  be  not  so,  the  in- 
strument is  imperfect,  for  the  object  is  not  to  go  through  the  form 
of  introducing  a  pessary- ;  it  is  to  rectify  the  malposition.  At  the 
next  and  at  every  subsequent  visit  of  the  patient,  this  examination 
should  be  made  before  removal  of  the  instrument,  in  order  to  test 
the  effect  of  time  and  movement  upon  the  position  of  the  supported 
uterus. 

I  do  not  know  that  any  better  opportunity  than  the  present  will 
occur,  for  offering  some  general  remarks  upon  the  use  of  pessaries. 
Uterine  pessaries  hold  a  prominent  position  among  surgical  appli- 
ances, as  a  means  of  procuring  palliative  and  curative  results. 
Like  all  other  mechanical  means,  which  are  powerful  for  good, 
they  are  capable  of  doing  a  great  deal  of  harm.  Were  I  asked  at 
the  present  moment  whether  I  believed  that  in  the  aggregate  they 
accomplished  more  good  or  evil,  I  should  be  forced  to  give  a  doubt- 


388  RETROVEKSION. 

ful  reply.  Their  injurious  consequences  I  would  attribute,  not  to 
the  instruments  themselves,  but  to  the  improper  manner  in  which 
they  are  very  often  used,  and  the  carelessness  with  which  they  are 
allowed  .to  remain  in  situ,  without  observation.  If  splints  were 
applied  to  broken  bones,  and  never  examined  until  union  was 
eilected,  their-  utility  would  soon  become  doubtful.  Pessaries 
should  be  carefully  watched,  for  they  sometimes  create  cellulitis, 
peritonitis,  and  vesico,  recto,  and  utero-vaginal  fistulae.  In  some 
cases  they  have  been  known  to  pass  completely  out  of  the  vagina, 
into  the  rectum  or  bladder.  Some  years  ago  a  case  entered  the  ser- 
vice of  Prof.  L.  A.  Sayre,  of  the  Bellevue  Hospital  Medical  College, 
presenting  very  obscure  symptoms  of  uterine  disease.  Examination 
proving  that  some  foreign  substance  existed  in  utero.  Prof.  Sayre 
dilated  ihe  cervical  canal,  and  extracted  a  glolje  i>essary  which  had 
migrated  from  the  vagina  into  the  uterus,  and  been  retained  there 
for  a  length  of  time. 

Whatever  instrument  be  cmjjloyed,  it  should  sustain  the  displaced 
uterus,  without  creating  pain  or  discomfort.  Should  any  such 
inconvenience  be  produced,  it  should  be  at  once  removed,  for  the 
most  violent  cellulitis  may  result.  While  a  pessary  is  kejit  in  tlie 
vagina,  cleanliness  should  be  secured  by  dail}'  vaginal  injections, 
and  at  intervals,  not  exceeding  two  months,  it  should  be  removed, 
examined,  and  reintroduced. 

One  of  the  difficulties  attending  the  use  of  tliese  instruments  in 
general  practice,  unquestionably  arises  from  the  fact  that  a  great 
deal  of  experience  is  necessary  before  any  one  can  use  them  with 
certainty  of  accomplishing  good  results.  But  another  is  due  to 
the  practitioner  having  only  a  small  supply  from  which  to  choose. 
He  who  habitually  employs  this  means,  should  have  at  his  disposal 
a  large  and  varied  assortment,  and  should  possess  sufficient 
mechanical  ingenuity  to  mould  and  adajjt  these  to  the  sjiecial  re- 
quirements of  cases  which  may  present  themselves.  The  vulcanite 
pessary  may  be  given  any  shape  after  being  heated,  and  Sims's 
block  tin  ring  may  be  readily  moulded  by  the  fingers. 

Whether  a  suit  for  malpractice  has  ever  arisen  on  account  of 
injury  done  by  a  pessary,  I  cannot  say,  but  I  can  easily  imagine 
such  a  source  of  litigation.  Every  practitioner  should  bear  in 
mind,  that  injury  done  by  a  pessary  does  not  argue  ignorance  on 
the  part  of  its  introducer.  When  one  removes,  as  every  gyne- 
cologist must  often  do,  a  pessary  from  a  position  in  the  pelvis  in 
which  it  has  become  imbedded,  and  finds,  as  its  result,  a  ragged, 
ulcerative  tract  existing,  he  is  very  apt  hastily  to  conclude  that 


PESSARIES.  38*.> 

the  instrument  was  improperly  apjJied.  This  is  by  no  means  always 
true.  I  have  repeatedly  removed  pessaries  under  these  circumstances, 
which  had  been  introduced  by  the  most  competent  gynecologists. 
How  common  it  is  to  find  a  pessary  which  one  has  carefully  in- 
troduced, turned  completely  upside  down  at  the  end  of  a  week. 
The  migratory  and  evolutionary  performances  of  the  vaginal  pes- 
sary are  truly  wonderful.  These  facts  being  recognized  and  ad- 
mitted by  all,  the  evident  deduction  is  that  it  is  unjust,  as  it  is 
unprofessional,  to  expose  to  a  patient,  at  the  expense  of  an  absent 
colleague,  every  lesion  which  these  difficult  instruments  may  have 
created.  To  tell  a  patient  that  the  instrument  she  wears  has 
made  a  deep  ulcer  in  the  vagina,  is  to  tell  her  that  her  attending 
physician  has  been  guilty  of  a  gross  blunder ;  for  "  ulcer,"  in  the 
popular  mind,  means  anything  that  is  frightful  in  the  way  of 
lesion,  from  erytliema  to  true  carcinoma.  And  although  the  state- 
ment is  literally  true,  he  who  makes  it  knows  that  the  same 
accident  has  happened  to  liimself  many  times,  that  a  week  of  rest 
will  entirely  efface  it,  and  that  no  real  damage  has  resulted  to  the 
patient  from  its  occurrence.  It  cannot  be  denied  that  even  in  our 
day  there  are  those  in  our  profession  whose  minds  have  not  yet 
become  disenthralled  from  the  prejudice  against  gynecology  which 
existed  up  to  a  century  ago.  These  too  often  forget  that  the  ob- 
servance of  professional  ethics  should  rise  superior  to  the  prompt- 
ings of  an  illiberal  sentiment,  of  which  every  day  is  proving  the 
injustice  and  fallacy.  It  is  a  matter  not  of  courtesy,  but  of  pro- 
fessional honor,  to  protect  the  interests  of  a  brother  practitioner, 
as  far  as  the  patient  is  concerned  ;  much  more  so,  where  the  ques- 
tion concerns  his  reputation  with  the  public  upon  whose  esteem 
his  usefulness  depends. 

Some  years  ago  a  case  in  point  occurred  to  me,  which  was  so  in- 
structive in  this  connection,  that  I  venture  to  detail  it.  A  lady 
called  upon  me  for  treatment  for  anteversion,  after  having  been 
for  some  months  under  the  care  of  an  advertising  charlatan  of 
this  country.  Upon  removing  a  very  coarse  and  clumsy  retro- 
version pessary,  I  found  a  deep  and  ragged  ulcer  which  had  pene- 
trated by  its  lower  extremity  into  the  tissue  intervening  between 
the  vagina  and  bladder.  It  was  deep,  large,  and  ragged.  The 
temptation  was  very  strong  to  expose  the  user  of  this  instrument, 
and  to  make  the  ulcer  the  text  of  a  discourse  upon  the  employ- 
ment of  ignorant  pretenders  by  the  public,  but  upon  second 
thought  I  refrained,  put  the  patient  upon  appropriate  treatment, 
and  as  she  lived  out  of  town,  directed  her  to  return  in  three 


390  FLEXIONS    OF    THE    UTERUS. 

weeks.  At  the  end  of  that  time  slie  reappeared,  and  as  the  ulcer 
had  healed,  and  all  vaginal  irritation  had  disappeared,  I  inserted 
an  anteversion  pessary,  and  sent  the  j^atient  home,  directing  her  to 
see  me  again  in  a  week,  as  that  proved  to  be  the  earliest  moment  at 
which  it  would  be  practicable.  In  a  week  she  returned,  and  to^ 
my  mortification  I  found  that  pressure  of  the  uterus  upon  the  pes- 
sary had  created  a  large  and  ragged  ulcer.  The  only  difference 
between  that  created  by  myself  and  by  the  charlatan,  was  that 
mine  was  a  little  the  larger  and  more  vicious  in  appearance. 

It  is  this  very  danger  which  now  makes  me  so  scrupulous  about 
examining  an  anteversion  pessary  repeatedly  during  the  first  ten 
days  of  its  sojourn  in  the  vagina. 

In  spite  of  all  its  attendant  evils,  the  use  of  the  pessary  is 
one  of  the  most  important  points  in  gynecology,  and  every  prac- 
titioner of  that  art  should  make  it  a  faithful,  special,  and  constant 
study.  I  confess  that  when  I  am  told,  as  I  sometimes  am  by  phy- 
sicians, that  they  never  use  pessaries,  because  they  are  so  strongly 
prejudiced  against  them,  the  question  ahvays  arises  in  my  mind, 
then  how  and  why  do  you  treat  uterine  diseases  ?  How  pessaries 
can  be  dispensed  with  is  to  me  one  of  the  unfathomable  mysteries 
of  gynecological  practice.  And  why  any  one  should  practise  an 
art  and  ignore  a  means  which,  properly  mastered,  constitutes  one 
of  the  most  powerful  and  reliable  of  its  resources,  is  equally  incom- 
prehensible. 


CHAPTER    XXIII. 

FLEXIONS  OF  THE  UTERUS. 

We  come  now  to  the  consideration  of  the  very  important,  inter- 
esting, and  difficult  subject  of  uterine  flexions.  Version,  or  turn- 
ing of  the  uterus,  signifies  the  fact  that  its  long  axis  has  clianged 
its  normal  direction  in  the  pelvis.  Flexion  signifies  the  bending 
of  the  uterus  upon  itself,  so  that  a  decided  angle  is  created  in  this 
long  axis.  One  condition  is  a  displacement;  the  other  a  deformity 
in  the  organ.  One  may  be  likened  to  a  dislocation  of  one  of  the 
long  bones;  the  other  to  a  fracture  with  angular  union  of  the 
broken  extremities.    One  involves  merely  restoration  of  a  dislocated 


FREQUENCY.  391 

organ  ;  the  other  rectification  of  a  deformity  which  may  have  lasted 
for  years,  or  may  even  have  been  congenitaL 

I  treat  of  flexions  under  a  separate  head  from  versions  because  I 
think  that  evil  results  from  an  opposite  course,  both  to  conciseness 
and  fulness  of  description.  Versions  are  commonly  accompanied 
by  flexions,  flexions  are  often  attended  by  a  certain  degree  of  ver- 
sion ;  flexions  in  time  produce  versions,  and  upon  a  jiure  version 
it  is  probable  that  a  flexion  is  sometimes  engrafted.  Nevertheless, 
if  we  desire  to  advance  in  our  knowledge  of  such  subjects,  we  must 
begin  by  separating,  not  uniting,  pathological  conditions,  merely 
because  they  commonly  complicate  and  give  rise  to  each  other. 

Frequency. — Flexions  of  the  uterus,  that  is,  displacements  ante- 
riorly, posteriorly,  or  laterally,  in  which  the  decidedly  predomi- 
nating feature  is  flexion  and  not  version,  are  very  common. 

In  339  displacements  Nonat       found  67  flexions. 
"     84  "  Meadows      "      54       " 

As  to  the  relative  frequency  of  anterior  and  posterior  flexions, 
the  evidence  is  decidedly  in  favor  of  the  former. 

In    67  cases  of  flexion  Nonat'  found    33  anteflexions  and    14  retroflexions. 
"     54         "         "          Meadows^       "        20  "  and    34 

"     54         "         "  Scanzoni^       "       46  "  and      8  " 

"     23         "         "  Valleix"         "       11  "  and    12 

'••  296         "         "  Hewitt^         "      184  "  and  112 

Out  of  1670  cases  of  flexion  collected  by  Ludwig  Joseph,^  of 
Breslau,  1100  were  anterior  and  570  posterior. 

Although  the  results  are  somewhat  conflicting,  the  preponder- 
ance of  evidence  very  decidedly  favors  anteflexion  over  retroflexion. 

One  reason  why  we  should  anticipate  that  retroflexion  would 
be  less  frequent  than  anteflexion,  is  that  the  natural  anterior 
obliquity  of  the  uterus  favors  tlie  latter  and  opposes  the  former 
displacement.  Another  is  the  fact  that  the  former  is  more 
thoroughly  guarded  against  by  ligamentous  support ;  the  round 
ligaments,  running  as  they  do  from  the  horns  of  the  uterus  to  the 
vulva,  decidedly  tending  to  prevent  its  occurrence.  !N'ot  only  do 
they  do  this ;  the  uterus,  being  kept  by  them  in  anterior  inclina- 
tion, should  softening  of  its  structure  occur,  or  any  direct  force  be 
exerted  upon  it,  naturally  bends  forwards. 

'  Mai.  de  TUterus,  p.  416.  2  x^m.  Journ.  Obstet,  1st  vol.  p.  176._ 

3  Klob,  op.  cit.,  p.  69.  •»  Cusco,  Thfese,  p.  35. 

®  Dis.  of  Women,  2d  Am.  ed.,  p.  213.  Dr.  Hewitt  includes  versions  with  flexions. 
The  other  statistics  refer  to  pure  flexion. 

^  Berlin  Beitrage  zur  Geburtshulfe  und  Gynakologie,  vol.  ii.  part  2,  1873. 


392  FLEXIONS    OF    THE    UTERUS. 

If  tliis  be  so,  it  may  be  asked  why  areolar  hyperplasia  so  fre- 
quently results  ill  retroflexion  as  well  as  in  anteflexion.  One 
reason  is  because  the  first  effect  of  the  increased  uterine  weight 
attending  that  disease  is  descent  of  the  uterus.  This  relaxes  the 
round  ligaments,  tends  to  bring  the  uterine  axis  in  coincidence 
with  that  of  the  middle  of  the  pelvis,  and  favors  retroflexion.  Fig. 
115  will  explain  this.  For  a  time  the  tendency  is  to  descent  and 
coincident  retroversion.  This  continues  until  the  progress  of  the 
cervix  is  checked  by  the  utero-sacral  ligaments. 
Fis:.  115.  Then  the  heavy  body  bends,  the  weakened  tissue 

yielding  at  the  os  internum,  and  retroflexion  re- 
sults. Another  reason  is  that  flexion  commonly 
follows  parturition,  at  which  time,  attacking  an 
organ  with  weakened  tissues  and  relaxed  liga- 
ments, it  meets  with  an  eflScient  ally  in  the  nurse, 
who  favors  retroflexion  at  the  expense  of  ante- 
flexion  by  zealously  forcing  the  fundus   back- 

The  uterus  descend-  ■,^.•^,^J^J^^■l         i 

i.,g  changes  its  axis,     wards  by  a  tight  obstetric  bandage. 

Anatomy. — Thanks  to  the  researches  of  Coste, 
Pouchet,  Bischoff",  and  others,  we  are  to-day  well  informed  con- 
cerning the  development  of  the  uterus.  Early  in  embryonic 
life  a  little  duct  shoots  out  from  the  external  surface  of  each 
Wolffian  body.  These  pass  downwards  to  unite  and  make  a  com- 
mon canal,  which  becomes  in  time  separated  into  uterus  and  vagina. 
Very  soon  a  constriction  appears,  the  neck  of  the  uterus  is  formed, 
and  becomes  well  developed,  while  a  very  small  spot  marks  the 
point  where  the  body  is  to  show  itself.  The  original  canals  be- 
come Fallopian  tubes,  and  at  the  time  of  birth  these,  as  well  as  the 
neck  and  body  of  the  uterus,  vagina,  and  other  organs,  have 
arrived  at  maturity.  But  it  must  not  be  supposed  that  the  pro- 
portions of  the  adult  uterus  exist  in  that  of  infancy.  The  neck 
forms  three-quarters  of  the  organ,  and  the  body,  represented  ])y  a 
soft  movable  membrane,  has  no  fixed  position,  but  follows  the 
bladder,  if  upon  opening  the  abdomen  it  is  drawn  forwards,  or  the 
rectum,  if  that  viscus  is  pushed  backwards.  Later  in  the  life  of 
the  girl,  even  after  she  has  reached  puberty  and  menstruation  has 
occurred,  the  uterus  is  curved  forwards  ;  and  this  anterior  inflexion 
lasts  through  life,  if  a  normal  state  continue,  though  it  is  generally 
diminished  and  sometimes  overcome  by  puberty  and  utero-gestation. 
In  1849,  Yelpeau,  whose  insight  into  gynecology  was  certainly 
remarkable,  in  a  discussion  before  the  Academy  of  Medicine  of 
Paris,  declared  that  he  had  so  often  found  an  anterior  inflexion  of 


ANATOMY.  393 

the  uterus  in  healthy  women,  that  he  was  inclined  to  look  upon  it 
as  normal.  Upon  this  hint  two  of  his  pupils,  Boullard,  (1852,)  and 
Piachaud,  (1853,)  with  great  assiduity,  investigated  the  subject,  and 
determined  that  it  is  so  in  the  child  and  virgin ;  the  latter  basing 
his  deductions  upon  107  cases.  Boullard  found  it  to  exist  in  80 
female  foetuses,  and  in  27  adult  females.  Verneuil  and  Follin  sub- 
sequently confirmed  these  observations. 

That  this  is  the  normal  condition  up  to  puberty  is  unquestionable; 
nor  can  it  be  denied  that  to  a  limited  degree  it  is  so  even  after- 
wards in  the  unmarried  female.  But,  as  Cusco  has  pointed  out,  it 
greatly  diminishes  at  puberty,  unless  abnormal  flexion  is  developed. 
Up  to  this  time  the  neck  of  the  uterus  represents  three-quarters  of 
its  entire  bulk,  and  the  whole  organ  is  an  insignificant  element  of 
the  human  body.  At  this  time,  however,  it  becomes  an  import- 
ant organ.  The  body  develops ;  its  walls  become  thick,  dense,  and 
strong ;  "  and,"  says  Cusco,  "  this  is  an  important  point,  if  the  de- 
velopment is  regular  its  walls  establish  an  equilibrium  ;  the  uterus 
straightens  itself;  its  anterior  concavity  disappears ;  and  there 
remains  only  a  slight  depression  corresponding  to  the  bladder." 
Up  to  this  period  of  life  it  is  unquestionably  due  to  the  want  of 
tone  and  power  which  characterizes  undeveloped  uterine  tissue,  for 
even  when  anteflexion  does  not  exist,  the  organ  is  generally  other- 
wise displaced.  Thus,  M.  Soudry,^  in  71  post-mortem  examinations 
of  infants,  found  the  uterus  anteflexed  41  times,  anteverted  11 
times,  retroverted  15  times,  retroflexed  twice,  and  retroverted  with 
anteflexion  twice.  We  may  then  conclude  fyom  the  evidence  at 
present  upon  record : 

1st.  That  anteflexion  is  the  rule  during  early  childhood ; 

2d.  That  it  is  quite  frequent,  in  slight  degree,  in  nulliparous 
women,  without  constituting  disease. 

For  the  prevention  of  versions  certain  pelvic  ligaments  are  very 
efiectual,  but  they  have  no  power  to  prevent  bending  of  the  uterus 
upon  itself.  This  is  accomplished  by  the  inherent  strength  and 
resistance  of  the  proper  tissue  of  the  organ.  Remove  a  normal 
uterus  from  the  cadaver,  balance  it  upon  the  cervix,  and  it  will 
sustain  itself  perfectly;  press  it  down  by  applying  force  to  the 
fundus,  and  its  own  resiliency  will  cause  it  to  erect  itself  imme- 
diately. Suppose  a  uterus  to  be  composed  of  gutta-percha  instead 
of  muscle;  the  ma+erial  forming  the  walls  of  the  neck  will  support 
the  fundus   when  the   pear-shaped  bag   is   held  by  the   stem  or 

'  Aran,  op.  cit.,  p.  981. 


394  FLEXIONS    OF    THE    UTEKUS. 

narrow  part.  To  carry  the  simile  further,  so  long  as  the  proper 
tissue  of  the  stem  or  neck  remains  normally  strong,  flexion  will 
be  impossible  unless  its  resistance  be  overcome  by  direct  physical 
force  exerted  by  pressure  or  traction.  But  if  some  influence  be 
brought  to  bear  locally,  so  as  to  soften  the  part  sustaining  the 
fundus,  it  is  evident  that  as  the  gutta-percha  wall  grows  weak, 
there  may  be  a  flexion  of  the  fundus  from  its  own  weight.  It  will 
be  said  that  these  views  represent  the  uterus  as  supported  by  the 
vagina  only,  and  leave  out  of  consideration  the  broad  ligaments 
which  sustain  the  fundus.  If  these  ligaments  were  tightly  drawn 
oords,  I  could  admit  their  action,  but  as  they  are  merely  lax  folds 
which  are  not  made  tense  by  the  bending  of  the  uterus  upon  itself, 
I  do  not  do  so. 

A  corroboration  of  this  view  is  found  in  the  frequency  of  flexions 
in  the  uteri  of  the  aged  which  have  lost  tone  and  strength.  "  In 
aged  women,"  says  Klob,^  "with  exceedingly  relaxed  uteri,  the 
pressure  of  the  intestines  upon  the  posterior  surface  of  the  organ  is 
suflicient  to  cause  anteflexion. 

Pathology. — Flexions  may  be  congenital  or  accidental.  As  the 
opposite  walls  develop  an  excess  of  nutrition  may  be  ajjpropriated 
by  one,  which  grows  rapidly,  while  the  other  developing  more 
slowly  arrests  the  erection  of  the  uterus  and,  giving  it  an  inflexion, 
creates  concavity  on  one  side  and  convexity  on  the  other.  If  the 
posterior  wall  develop  most  decidedly,  an  anteflexion  results ;  if,  as 
was  the  case  in  nineteen  out  of  M.  Soudry's  seventy-one  autopsies 
of  infants,  posterior  displacement  exist  and  the  anterior  wall  receive 
the  chief  amount  of  nutrition,  a  retroflexion  is  the  consequence. 
But  not  only  does  the  excessive  growth  of  one  wall  create  an 
inflexion  on  the  opposite  side ;  the  side  which  is  bent  undergoes  to 
a  certain  extent  atrophy,  and  tliis  increases  the  already  growing 
disproportion.  This,  in  all  probability,  is  the  source  of  congenital 
flexion,  a  condition  always  exceedingly  diflacult  of  cure,  but  fortu- 
nately one  whicli  does  not  create  as  much  corporeal  congestion  and 
constitutional  disturbance  as  the  more  remediable  form  which  is 
accidental. 

Congenital  anteflexion  is  much  more  common  than  congenital 
retroflexion.  Cases  of  the  latter  are,  however,  by  no  means 
unknown.  Boivin  and  Duges^  report  two  cases,  Dubois  one, 
Deville  one,  and  Bell  one  in  a  very  young  girl.  I  have  several 
times  met  with  it. 

'  Op.  cit.,  p.  61.  2  Cusco,  op.  cit.,  p.  34. 


PATHOLOGY.  395 

Any  influence  which  weakens  the  tissue  constituting  the  uterine 
walls,  creates  flexion.  If  the  posterior  wall  be  chiefly  affected,  the 
body  falls  backwards ;  if  the  anterior,  it  inclines  forwards ;  if  both, 
the  direction  of  inclination  is  decided  by  extraneous  forces.  Roki- 
tansky  has  proved  that  such  weakening  is  accomplished  by  endo- 
metritis, which  creates  an  inward  growth  of  the  utricular  glands 
into  the  submucous  connective  tissue,  near  the  os  internum,  which 
in  consequence  undergoes  atrophy  and  enfeeblement ;  or  by  cystic 
degeneration  in  the  cervical  glands,  "■  which  from  their  increased 
size  and  consequent  pressure,  cause  the  submucous  stratum  to 
become  atrophied,  and  which  ultimately  bursting,  thereby  cause  a. 
collapse  of  tissue  in  the  formerly  dense  framework  of  the  uterus, 
leaving  in  its  place  a  flaccid  net-like  areolar  tissue  incapable  of 
sustaining  the  organ  in  its  normal  position."  Both  these  occur- 
rences, says  Klob,  take  place  quite  frequently.  Rokitansky  says  that 
in  the  anterior  semi-circle  of  the  uterine  tissue  around  the  os  inter- 
num of  women  who  have  borne  many  children,  a  large  transverse 
vein  is  found,  which,  by  its  removal  of  tissue,  weakens  the  wall. 

But  there  are  other  influences,  which  may  accomplish  this 
result :  abscess  of  the  uterine  tissue ;  development  of  fibroids  which 
disorder  the  bloodvessels;  varicose  degeneration  of  the  veins  and 
sponginess  of  tissue  engendered  by  prolonged  traction  upon  the 
neck ;  disturbance  of  nutrition  by  flexure  created  suddenly  by  a 
blow  or  fall,  or  gradually  by  traction  from  false  membranes;  sub- 
involution, or  areolar  hyperplasia,  which  accomplishes  on  a  large 
scale,  the  substitution  "  for  the  dense  framework  of  the  uterus  of  a 
flaccid,  net-like  areolar  tissue,  incapable  of  sustaining  the  organ," 
which  Rokitansky  declares  occurs  at  the  os  internum  in  cystic 
degeneration. 

This  loss  of  power  in  one  or  both  walls  of  the  uterus  is  frequently, 
though  not  universally,  the  cause  of  flexions  of  accidental  character. 
They  are  sometimes  due  to  force  sufliciently  strong  to  overcome 
the  resisting  power  of  the  uterine  tissue,  either  suddenly  or  by  slow 
degrees.  Once  flexed,  the  wall  soon  undergoes  degeneration,  and. 
thus  two  causes  for  a  continuation  of  the  condition  are  combined. 

The  point  of  greatest  weakness  is  the  point  at  which  flexion 
occurs,  and  this  is  usually  opposite  the  os  internum.  In  anteflexion 
it  may  occur  below  this  point,  when  the  neck  only  is  flexed,  from 
prolonged  and  habitual  constipation.  In  retroflexions  I  have  known 
it  occur  at  the  middle  of  the  body,  and  escape  superficial  exami- 
nation, or  induce  a  belief  in  the  existence  of  fibrous  tumor. 
Klob  has  noticed  this  bilt  once,  and  has  failed  to  find  an  analogous 


396  FLEXIONS    OF    THE    UTERUS. 

instance.  Cusco^  records  one  case  in  his  own  experience  where  the 
body  was  equally  divided  by  a  flexion,  and  quotes  Ashwell  and 
Bell  for  others  of  similar  character. 

These  are  the  influences  under  which  flexion  is  induced.  No 
sooner  does  it  occur,  than  a  marked  change  takes  place  in  the 
uterine  circulation.  The  uterine  bloodvessels  arise  from  the  arteria 
uterina  hypogastrica,  the  arteria  uterina  aortica,  and  from  the 
arteria  spermatica  externa.^  The  veins  make  up  by  their  union 
two  plexuses,  the  uterine  and  pampiniform.  All  these  vessels  go 
to  and  come  from  the  uterus  at  its  sides.  A  flexion  of  this  organ 
.to  a  certain  extent  ligates  these  vessels,  as  Hewitt  expresses  it, 
and  interferes  with  circulation  directly  and  immediately.  The 
incompressible  arteries  still  carrj''  blood  to  the  body,  Init  the  com- 
pressible veins  fail  to  return  it  to  the  general  circulation,  and  the 
consequences  are  congestion,  oedema,  and  in  time  hypergenesis  of 
tissue.  This  important  fact  Dr.  Hewitt,  in  his  recent  admirable 
edition  of  his  work  upon  Diseases  of  Women,  lays  so  nmch  stress 
upon,  as  to  make  it  the  pivotal  point  of  his  pathological  creed. 
There  can  be  no  question  of  the  truth  of  this  view,  nor  of  its 
iextremely  important  pathological  bearing.  In  bringing  it  promi- 
nently forward,  and  insisting  upon  its  frequent  and  striking  ettects 
as  a  factor  in  uterine  disorders,  Dr.  Hewitt  has,  in  my  judgment, 
done  a  great  deal  of  good.  He  is  in  error,  however,  in  supposing 
that  it  had  })reviously  been  unrecognized,  as  the  following  passage 
from  his  work  announces:  "  It  is  somewhat  surprising  that  the  occur- 
rence of  mechanical  congestion  of  the  body  of  the  uterus, arising  from 
mere  change  of  shape  of  the  organ,  as  above  pointed  out,  should 
not  have  attracted  the  attention  of  uterine  pathologists."  Since 
the  appearance  of  Prof,  Klob's  work  on  Pathological  Anatomy, 
published  in  1868,^  it  had  especially  attracted  my  attention,  and 
had  constituted  a  prominent  feature  in  my  teachings.  Klob*  de- 
clares that  "a  further  consequence  of  venous  hyperremia,  arising 
from  hindered  reflux  of  blood  at  the  point  of  flexion,  is  cedema 
with  tumefaction  and  genuine  hypertrophy  of  the  body  of  the 
uterus.  The  reflux  of  blood  from  the  uterine  to  the  hypogastric 
veins  is  interrupted,  and  in  consequence  of  the  collateral  hyper- 
semia,  frequently  a  very  considerable  dilatation  of  the  plexus  pam- 
piniformis  takes  place,  because  the  blood  can  now  only  flow  through 


'  Op.  cit.,  p.  37.  2  Strieker's  Manual  of  Histology. 

3  Dr.  Hewitt's  views  were  first  published  in  an  article  read  before  the  British 
Medical  Association  at  Leeds  in  1870. 
"  Op.  cit.,  p.  (iO. 


EESULTS    AND    COMPLICATIONS.  397 

the  spermatic  vein."  Under  this  mechanical  influence  both  neck 
and  body  become  tumid,  tender,  and  painful;  the  mucous  lining- 
is  so  congested  as  to  give  forth  excessive  amounts  of  mucus  and 
blood ;  and  the  tissues  of  the  organ,  excited  to  excessive  growth  by 
prolonged  l)lood  stasis,  undergo  in  time  marked  hypergenesis. 

At  the  point  of  flexion  the  cervical  canal  is  always  more  or  less 
closed  by  apposition  of  its  walls.  From  this  cause  the  ingress  of 
fluids  is  prevented,  and  sterility  commonly  results,  and  the  egress  is 
interfered  with  to  such  an  extent,  that  dysmenorrlicea,  hemato 
metra,  hydrometra,  and  accumulations  of  mucus  take  place.  Of 
course  such  accumulations  cannot  occur  with  impunity;  they  result 
in  the  production  of  endometritis  and  even  in  hematocele  by  regur- 
gitation. 

In  congenital  flexion  the  circulation  of  the  uterus  is  so  gradually 
interfered  with  that  marked  congestion  is  not  so  likely  to  occur  as 
it  is  when  the  organ  is  suddenly  bent  upon  itself,  nor  is  occlusion 
of  the  cervix  ordinarily  so  complete. 

Results  and  Complications. — Already  the  reader  can  enumerate 
for  himself  many  of  the  consequences  arising  from  flexion  of  the 
uterus;  and  a  list  of  them  placed  before  him  will  need  little  further 
explanation  as  to  the  mode  of  their  production.  They  are  the 
following: 

Congestion ; 

Hypergenesis  of  tissue; 

Sterility ; 

Dysmenorrhoea ; 

Menorrhagia; 

Endometritis; 

Tendency  to  abortion; 

Hematocele ; 

Ovaritis  and  Salpingitis; 

Pelvic  peritonitis; 

Fluid  accumulations  in  utero;* 

Uterine  neuralgia; 

Cystitis  and  Rectitis; 

Granular  degeneration. 

When  it  is  remembered  that  each  of  these  aflfections  sets  up 
symptoms  and  complications  of  its  own,  it  will  be  appreciated 
that  flexion  of  the  uterus  is  a  disorder  which,  apparently  insignifi- 
cant in  itself,  is  the  source  of  many  grave  results. 


'  Kiwisch  reports  a  case  of  hydrometra. 


398  FLEXIONS    OF    THE    UTERUS. 

])crjuigc(l  ntorine  eirciilatioii  produces  incnstrual  (liRorder. 
UHUiilly  this  consists  in  excessive  flow,  but  sometimes  the  opposite 
condition  exists. 

Oviiriah  conircstion,  neuralgia,  and  enlargements,  as,  likewise, 
catarrh  oi"  the  Fallopian  tuhes,  are  probably  due  to  a  reflex  influ- 
ence transmitted  through  \]\r  intimate  and  sensitive  nervous  con- 
nections between  the  utci-us  and  these  organs.  Rigby  attributed 
them  to  pressure,  but  this  does  not  appear  to  account  for  those  con- 
ditions. 

Peritonitis  results  from  pressure  and  friction  by  the  displaced 
fundus,  and,  in  some  cases,  from  reflux  through  the  tul)e8  of 
imprisoned  fluids.  It  is  by  no  means  rare;  so  common,  indeed, 
that  Virchow  regards  traction  by  false  membranes  as  the  chief 
cause  of  anteflexions.  That  this  pathologist  is  in  error  ui)on  tliis 
point  is  the  belief  of  all  others  with  wliose  views  I  am  familiar.* 

Predisposing  Causes. — Any  cause  wliich  predisposes  to  enfeeble- 
ment  of  uterine  tone,  to  the  developnKMit  of  a  force  which  overcomes 
this  even  when  unimpaired,  or  still  more  one  which  c(mibines  the 
two  evil  influences,  prepares  the  way  ibr  flexure  of  the  uterus  under 
the  imi>ulse  given  by  a  sudden  or  }>ersi8tent  exciting  cause.  They 
may  be  thus  enumerated: 

I'arturition; 

Impoverisliment  of  the  l)lood; 
Enfeebled  nerve  state; 
Extreme  youth  or  age; 
Laborious  occu}tation  ; 
Relaxation  of  abdominal  walls; 
Influences  allering  ^lelvic  axes. 

Exeitiiif)  Causes. — One  of  the  functions  of  the  cervix  uteri  is  to 
support  the  body,  and  for  the  fiei'foi-mance  of  this  it  is  abundantly 
competent,  unless  its  powers  be  imjiaired  by  one  of  the  following 
inllucnces: 

Injlu.ences  ircakcnivg  vtcrine  support. 
Endometritis; 

Cystic  degeneration  near  os  internum; 
Pregnancy ; 
Patty  degeneration ; 
Areolar  hyperplasia; 
Vascular  desceneration  in  uterine  walls. 


Joseph  of  Breslttu  agrees  with  Virchow. 


EXCITING    CAUSES.  399 

Influences  increasing  the  weight  of  the  fund  ua. 
Enlargement  of  the  body ; 
Pregnancy ; 
Tumors ; 
Accumulation  of  fluid  in  utero. 

Influences  pushing  the  fun// us  or  cervix  forwards  or  backwards. 
Abdominal  or  pelvic  tumors- 
Ascites ; 

Fecal  accumulation; 
Tight  clothing; 
Muscular  efforts. 

Influences  exerting  traction  forwards  or  backwards. 
False  membranes  from  pelvic  peritonitis. 

Of  the  first  class  of  causes,  inflammation  aft'ecting  the  mucous 
membrane  of  the  neck,  and  creating  areolar  hyperplasia  in  the 
parencliyma  is,  according  to  my  experience,  one  of  the  most  fre- 
quent. The  hyperplasia  thus  arising  results  in  atrophy  of  the 
muscular  and  submucous  fibrous  structures  of  the  uterus  and  their 
rei)lacement  by  hypertrophied  areolar  tissue,  and  produces  a  marked 
tendency  to  this  deviation  by  thus  substituting  a  lax  and  feeble  for 
a  dense  and  powerful  substance.  Klob  declares  that  this  replace- 
ment of  strong  tissue  by  that  which  is  weaker  occurs  more  espe- 
cially near  the  os  internum.  Virchow  denies  the  agency  of  this 
condition  as  a  causative  influence,  as  he  likewise  does  that  of  fatty 
degeneration,  observed  by  vScan^coni,  at  the  point  of  flexure.  The 
influence  of  parturition,  abortion,  and  pregnancy  has  been  admitted 
by  all  authorities. 

The  varieties  coming  under  the  head  of  the  second  set  of  causes 
are  all  universally  admitted,  as  are  also  those  belonging  to  the 
third.  Fecal  impaction  may  sometimes  produce  flexion  of  the 
body,  and  frequently  causes  the  cervix  to  bend  sharply  forwards. 
The  fourth  set  of  causes  is  beyond  question,  in  autopsies  the  uterus 
being  often  found  thus  bound  in  a  state  of  flexion. 

The  etiology  of  cervical  flexion  is  somewhat  different  from  that 
of  corporeal.  It  is,  I  feel  satisfied,  generally  induced  b}^  pressui-e 
directly  exerted  upon  the  uterus  by  tight  clothing,  which  forces 
it  against  the  concave  surface  of  the  vagina.  This  surface  gives 
the  impinging  part  a  slant  forwards,  and  keeps  it  thus  bent.  Ha* 
bitual  constipation  increases  this  vicious  curve,  and  the  tAvo  causes 
combined  often  result  in  this  unmanageable  form  of  the  affection. 
This  explains  the  fact,  which  all  must  have  noticed,  that  in  pure 


400  FLEXIONS    OF    THE    UTEEUS. 

corporeal  flexion  the  uterus  is  often  high  up  in  the  pelvis,  while 
in  that  of  cervical  form  it  is  almost  invariably  low  down.  It  like- 
wise explains  what  my  observation  leads  me  to  regard  as  a  fact, 
that  in  nulliparous  women  the  cervical  and  cervico-corporeal 
varieties  preponderate  in  frequency  over  the  corporeal  form,  which 
is  generally  met  with  in  multiparous  women. 

There  is  still  another  pathological  element  which  enters  into 
the  etiology  of  cervical  flexions,  and  explains  the  phenomena  with 
regard  to  them,  which  I  have  just  mentioned.  The  uterus  being 
forced  downwards  by  influences  exerting  themselves  upon  the 
abdomen,  if  the  utero-vesical  ligaments  be  lax  and  yielding,  cor- 
poreal flexion  will  occur,  the  cervix  retreating  under  pressure. 
If,  however,  these  ligaments  keep  the  cervix  in  close  contact  with 
the  bladder,  cervico-corporeal  or  pure  cervical  flexion  will  be  de- 
veloped. Parturition  does  more  to  stretch  these  ligaments  than 
anything  else,  and  thus  cervical  flexion  is  not  so  generally  met 
with  in  women  who  have  gone  through  that  process  as  in  those 
who  have  not.  Corporeal  flexion  is  the  variety  seen  after  par- 
turition ;  the  cervical  and  cervico-corporeal  forms,  those  which  we 
see  in  nulliparous  women.  Not  only  is  this  fact  interesting  in 
reference  to  pathology;  it  has  an  important  bearing  upon  the 
treatment  of  cervical  flexions.  lie  who  would  treat  these  cases 
successfully  must  systematically'  ^stretch  the  ligaments  which  keep 
the  cervix  in  an  anterior  jjosition,  and  by  this  means  strive  to 
change  the  form  of  displacement  to  that  of  corporeal  flexion,  or  of 
anteversion. 

Retroflexion  is  most  frequently  the  result  of  some  influence  which 
weakens  the  tone  of  the  uterine  walls,  but,  even  when  this  is  normal, 
any  force  directly  applied  mav  overcome  it  and  produce  a  flexure, 
whether  such  force  is  developed  suddenly  or  gradually. 

We  have  now  pursued  the  study  of  flexions,  as  a  whole,  as  far 
as  it  is  profitable  to  do  so ;  and,  from  this  point,  they  shall  be 
considered  under  separate  heads. 

The  uterus  may  be  flexed  upon  itself  anteriorly,  posteriorly,  or 
laterally,  giving  rise  to  the  disorders  known  as — 

Anteflexion ; 
Retroflexion ; 
Latero-flexion. 

The  fundus  in  falling  forwards  or  backwards  does  not  always 
preserve  the  median  line,  but  commonly  falls  obliquely  to  the  right 
or  left.    This  obliquity  is  frequently  created  uven  where  the  median 


VARIETIES.  401 

line  was  originally  preserved  by  the  use  of  a  pessary,  and  consti- 
tutes so  prominent  a  difficulty  in  these  cases  that  I  employ  a  special 
instrument  for  its  treatment. 

Thus  we  may  find  a  uterus  flexed  forwards  and  laterally ;  back- 
wards and  forwards  ;  backwards  and  laterally,  etc. 

These  varieties  are  known  as — 

Retro-anteflexion ; 
Retro-lateroflexion ; 
Ante-retroflexion ; 
Latero-anteflexion,  etc. 

The  student  need  not  memorize  these,  but  merely  keeping  in 
mind  the  fact  that  such  combinations  are  possible,  he  will  readily 
recognize  them  at  the  bedside  if  he  have  mastered  the  three  chief 
forms. 

As  I  have  elsewhere  alluded  to  the  statistics  of  Nonat*  upon  the 
relative  frequency  of  displacements,  it  may  not  be  uninteresting 
to  give  his  full  table  before  closing  this  subject. 

nonat's  statistical  table. 

Number  of  cases  examined 339 

Anteversion, 135 

Retroversion, 67 

Anteflexion, 33 

Retroflexion, .14 

Lateroflexion, 1 

Retro-anteflexion, .  10 

Prolapsus, 2 

Retro-lateroflexion, 1 

Retro-latero  version, 2 

Ante-retroflexion, 2 

Lateroversion, 1 

Latero-anteflexion, 4 

Ante-lateroflexion, 2 

Not  specified, 65 

•  Op.  cit.,  p.  416. 


2fi 


402 


ANTEFLEXION, 


CHAPTER    XXIV. 


ANTEFLEXION. 


Definition. — This,  which  is  one  of  the  most  frequent  of  all  uterine 
displacements,  consists  in  a  hcnding  of  the  organ  so  that  the  fundus, 
the  cervix,  or  hoth,  are  hent  more  or  less  sharply  forwards. 


Fifr  llfi. 


Anteflexion. 


Varieties. — There  are  three  forms  of  anteflexion:  first,  corporeal 
flexion  ;  second,  cervical  flexion  ;  third,  cervico-corporeal  flexion. 

1st.  The  cervix  heing  normal  in  position  the  body  is  flexed  ; 
2d.  The  body  being  normal  in  position  the  cervix  is  flexed; 
3d.  Both  are  flexed  forwards. 

The  lines  represented  in  Fig.  117  will  serve  to  show  the  devia- 
tions which  may  aifect  the  axes  of  body  and  cervix. 

These  varieties  are  neither  arbitrary  nor  unnecessai>.  The 
existence  of  each  may  readily  be  verified  at  the  bedside,  and  treat- 
ment should  always  be  materially  modified  by  the  peculiarity  of 
the  deviation.     It  appears  to  me  that  a  neglect  of  them  and  the 


SYMPTOMS.  403 

fixation  of  attention  upon  flexure  of  the  body  alone  has  seriously 
retarded  progress  in  treatment.  N^o  one  can  intelligently  treat 
anteflexion  without  regard  being  had  to  the  variety  of  the  disorder 
to  which  he  is  called  upon  to  adapt  his  mechanical  appliances. 

Fiff.  117. 


(    <-    L 


Normal  axes.  First  variety  of  Second  variety  of  Third  variety  of 

flexion.  flexion.  flexion. 

In  addition  to  these  there  is  a  rare  form  in  which  the  cervix  is 
flexed  forwards  and  the  body  backwards,  but  it  is  diflicult  to  repre- 
sent the  axes  of  this  variety  in  a  diagram. 

SyiniJtoms. — A  certain  degree  of  this  displacement  may  exist  for 
years  without  the  development  of  symptoms.  Very  generally, 
however,  obstruction  to  venous  return  at  the  point  of  flexure  pro- 
duces congestion  which  increases  the  displacement,  disturbs  the 
nervous  system,  and  disorders  uterine  functions.  Then  the  follow- 
ing symptoms  develop  themselves: 

Pain  over  hypogastrium  and  in  groins  and  back; 

Irritable  bladder; 

Leucorrhoea ; 

Dysmenorrhoea ; 

Sterility ; 

IN^ervous  disturbance  and  despondency ; 

Pain  on  locomotion; 

Menorrhagia ; 

Tendency  to  abortion ; 

Pain  on  sexual  intercourse; 

Pelvic  neuralgia; 

Sense  of  depression  at  the  epigastrium. 

In  some  cases  there  is  a  morbid  and  invincible  aversion  to  walk- 
ing, partly  arising  from  physical  and  partly  from  mental  causes.  I 
have,  in  several  cases,  seen  women  who  had  been  bed-ridden  for 
three  and  four  years  rapidly  restored  to  their  powers  of  locomotion 
by  restoration  of  the  uterus  to  position,  and  its  retention  by  an 
efficient  pessary. 

Dr.  Hewitt  mentions  the  retention  of  secundines  after  abortion 
in  cases  of  anteflexion,  and  their  putrefaction  in  utero,  and  advises 


404  ANTEFLEXION. 

as  treatment  restoring  the  organ  to  place,  when  expulsion  at  once 
occurs. 

Physical  Signs.— A&  the  finger  passes  into  the  vagina  and  touches 
the  cervix,  nothing  abnormal  will  usually  be  discovered.  But  as 
it  sweeps  along  the  anterior  wall  of  the  uterus,  about  the  os 
internum  a  protuberance  will  be  met  with  which  presses  upon  the 
bladder.  The  finger  which  has  thus  far  explored  being  kept  in 
contact  with  this  mass,  the  disengaged  hand  should  then  be  laid 
upon  the  abdomen  and  made  to  depress  the  anterior  abdominal 
wall  so  as  tO  approximate  the  finger  in  the  vagina.  By  this  means 
the  shape,  size,  and  sensitiveness  of  the  body  may  be  ascertained. 
The  diagnostician  is,  however,  still  in  doubt  whether  the  enlarge- 
ment may  not  be  one  due  to  fibrous  tumor  or  cellulitis.  This  point 
he  settles  by  placing  the  patient  on  the  side,  introducing  Sims's 
speculum,  and  gently  probing  the  uterus  to  the  fundus.  Giving  to 
the  probe  the  curve  which  by  vaginal  touch  he  has  been  informed 
is  that  of  the  uterus,  he  carefully  passes  it  in.  Should  it  not  pro- 
ceed without  obstruction,  he  withdraws  it,  alters  the  curve,  and  tries 
again.  Having  succeeded  in  introducing  it,  he  learns  the  course 
of  the  uterine  canal,  its  length,  and  the  sensitiveness  of  its  walls. 
Should  the  probe  have  entered  the  mass  felt  through  the  vagina, 
that  mass  is  the  uterine  body.  Sliould  it  go  in  the  normal  axis  or 
backwards,  it  is  not  the  uterine  body,  but  some  growth  in  contact 
with  it.  In  pure  cervical  flexion  the  neck  will  be  felt  sharply  bent 
forwards  and  in  the  double  form  both  neck  and  body  will  be  found 
flexed. 

Prognosis. — The  prognosis  as  to  cure  will  depend  upon  certain 
circumstances  which  I  will  proceed  to  enumerate. 

{a.)  It  is  better  in  multiparous  than  in  nulliparous  women, 
because  the  vagina  in  the  former  more  readily  admits  of  the  use 
of  mechanical  supports,  and  because  it  is  acquired  and  not  con- 
genital. 

(/;.)  It  is  better  in  pure  corporeal  anteflexion  than  in  those  varie- 
ties in  which  the  cervix  is  affected. 

(c.)  Where  the  cervix  is  thrown  far  back  and  lifted  high  in  the 
pelvis,  the  prognosis  is  decidedly  unfavorable,  and  more  especially 
if  there  exist  only  a  scanty  vaginal  pouch  anterior  to  the  neck. 

{d.)  If  the  flexion  be  of  reducible  kind,  prognosis  is  favorable; 
if  the  contrary,  it  is  by  no  means  so. 

(f.)  The  prognosis  of  congenital  flexion  is  almost  a  hopeless  one, 
unless  the  knife  be  resorted  to. 

(/.)  Of  all  the  cases  except  the  last  the  prognosis  is  most  un- 


TREATMENT.  405 

favorable  in  those  in  which  the  vagina  joins  the  cervix  very  low 
down,  near  the  os  externum,  and  where  the  uterus  is  held  high  in 
the  pelvis. 

As  regards  the  general  health  of  the  patient,  the  prognosis  is  not 
usually  bad,  but  enlargement  of  the  uterine  body  may  result  from 
anteflexion,  and  its  consequences  are  commonly  sterility,  vesical 
irritability,  dysmenorrhoea,  and  leucorrhoea. 

Treatment. — I  shall  consider  the  treatment  of  anteflexion  under 
three  different  circumstances:  reducible  flexion  in  which  the  body 
is  displaced;  reducible  flexion  in  which  the  neck  is  displaced: 
irreducible  flexion  in  which  the  neck  alone,  or  both  body  and  neck, 
are  bent  forwards. 

Reducible  Flexion^  body  bent  forwards,  axis  of  neck  normal. — The 
indications  for  treatment  are  very  simple :  to  restore  and  retain  the 
flexed  part.  The  fulfilment  of  the  first  alone  is  unimportant,  as 
the  part  restored  to  position  falls  out  of  it,  as  soon  as  the  restoring 
power  is  removed.  It  must  be  borne  in  mind  that  flexions  are 
unlike  versions  in  respect  to  rapidity  of  production.  Versions 
commonly  occur  suddenly  from  some  violent  disturbing  influence, 
under  which  circumstances  they  are  susceptible  of  immediate 
relief.  We  have  proof  that  flexions  are  sometimes  thus  induced, 
though  by  no  means  commonly  so,  unless  occurring  during  preg- 
nancy. They  are  usually  the  consequences  of  influences  long  kept 
up,  and  can  rarely  be  overcome  with  any  reasonable  hope  that  they 
will  not  immediately  recur. 

As  to  the  second  indication  it  may  be  said  that  the  prognosis  as 
to  its  successful  accomplishment  is  very  favorable,  unless  we  have 
to  deal  with  a  shallow  anterior  vaginal  pouch;  more  so  in  these 
than  in  any  other  form  of  this  displacement. 

The  bowels  having  been  evacuated,  and  pelvic  and  vaginal  irri- 
tation removed  by  warm  vaginal  injections  and  rest  in  the  dorsal 
decubitus,  local  treatment  should  be  commenced  thus:  the  uterine 
sound  being  introduced  to  the  fundus,  not  much  curved,  but  as 
straight  as  it  can  be  made  to  pass,  the  handle  being  held  in  one 
hand,  the  tips  of  the  fingers  of  the  other  should  be  pressed  against 
the  shaft  of  the  sound  near  the  middle,  and  they  being  made  a 
fulcrum,  the  handle  should  be  carried  to  the  symphysis.  By  this 
manoeuvre  the  flexed  fundus  is  elevated,  and  at  the  same  time 
carried  towards  the  hollow  of  the  sacrum.  This  point  being  reached, 
the  sound  should  be  very  gently  rotated,  and  conq)lete  retroversion 
with  partial  retroflexion  of  the  uterus  accomplished.  This  should 
be  done  with  the  utmost  gentleness,  and  as  I  have  described,  not 


406  ANTEFLEXION. 

by  a  sudden  rotation  of  the  flexed  organ,  which  forcibly  sweeps  the 
fundus  around  the  superior  strait  of  the  pelvis. 

The  instrument  represented  in  Fig.  100  or  that  shown  in  Fig.  101 
should  now  be  applied,  the  patient  kept  for  a  few  days  upon  the 
back  in  bed,  tlie  bladder  kept  distended  by  urine,  and  the  abdominal 
walls  forced  inwards  by  an  ordinary  obstetric  bandage  with  a  folded 
towel  under  it  as  a  compress. 

At  the  end  of  a  week  examination  will  generally  show  marked 
amelioration  of  the  displacement.  Then  the  sound  should  be  again 
introduced,  the  uterus  held  in  retroflexion  for  two  or  three  minutes, 
the  pessary  restored,  the  obstetric  binder  replaced  by  one  of  the 
abdominal  bandages  elsewhere  shown,  all  weight  removed  from  the 
abdomen  by  a  skirt  supporter,  and  the  patient  allowed  gradually  to 
resume  her  duties.  If  she  do  not  sufler  from  the  support  used,  it 
need  not  be  altered;  if  she  do  so,  the  anteversion  pessary,  Fig.  95, 
Fig.  98,  or  some  other  may  be  made  to  replace  it. 

Should  the  bulb  of  the  pessary  in  the  beginning  prove  painful, 
it  may  with  great  advantage  be  rejilaced  by  a  soft  sponge.  This 
will  necessitate  the  removal  of  the  instrument  once  in  every 
twenty-four  hours. 

With  considerable  hesitancy  I  shoAv  the  anteflexion,  (not  ante- 
version,)  pessary,  the  mode  of  action  of  which  is  perfectly  shown 
in  Figs.  118  and  119. 

Fig.  119. 


OARROW-CO.. 


Anteflexion  pessary  being  introduced.  The  same  after  introduction. 

The  bulb  on  the  end  of  the  stem  rests  just  under  the  fundus,  the 
ring  receives  the  tip  of  the  cervix,  and  the  movable  branches  rest 
against  the  tissues  under  the  pubes.  This  pessary  sustains  the 
anteflexed  body  perfectly.  My  hesitancy  in  recommending  it  is 
not  based  upon  its  inefficiency,  but  upon  the  facts  that  it  is  impos- 
sible for  the  patient  to  remove  it,  and  dilflcult  even  for  the  physi- 


TREATMENT.  407 

cian  to  do  so.  To  flex  the  stem  and  bring  the  bnll)  down  so  as  to 
pass  the  pubic  arch,  as  shown  in  Fig.  118,  the  finger,  or  a  curved 
instrument,  must  be  passed  over  it.  For  these  reasons,  although  I 
have  employed  it  for  years,  I  have  never  before  published  it,  and 
I  should  recommend  none  but  experts  to  resort  to  it. 

Reducible  Flexion^  neck  bent  f(yrward^  axis  of  body  norincd. — The 
treatment  of  such  a  case  as  this  sliould  be  entirely  difterent  from 
that  of  the  last  mentioned.  Is  it  not  evident  that  means  directed 
to  rectification  of  the  axis  of  the  body,  which  is  normal,  ignoring 
the  jiosition  of  the  neck,  which  is  abnormal,  is  contrary  to  reason? 
It  is  the  neck,  and  not  the  body,  which  is  distorted,  and  which 
consequently  needs  treatment. 

The  patient  having  been  prepared  for  treatment,  as  in  the  pre- 
vious case,  the  sound  should  be  gently  carried,  with  a  sliglit  for- 
ward bend  only,  to  the  fundus,  and  the  body  tlirown  and  held 
backward  for  several  minutes,  in  order  to  straighten  the  uterine 
canal.  If  it  be  found  to  do  this,  and  the  reducible  character  of  the 
case  be  demonstrated,  there  are  two  methods  by  which  the  normal 
direction  of  the  uterine  axis  can  be  preserved :  one,  the  use  of  the 
intra-uterine  stem,  soon  to  be  described  ;  the  other,  the  use  of  a 
pessary,  which  will  bend  the  cervix  backwards,  and  keep  it  so  in- 
clined. In  the  treatment  of  such  a  case,  the  practitioner  must  bear 
in  mind,  that  two  indications  must  be  fulfilled  for  the  accomplish- 
ment of  cure:  first,  stretching  of  the  utero-vesical  ligaments,  in 
order  that  the  cervix  may  retreat  towards  the  sacrum  ;  second, 
bending  the  neck  into  the  proper  axis.  After  the  utero-vesical 
ligaments  and  uterine  parenchyma  have  been  repeatedly  stretched 
by  the  sound,  and  the  canal  temporarily  straightened,  the  pessary 
of  Dr.  Hurd,  of  West  Point,  Miss.,  should  be  introduced.  This 
instrument,  which  is  shown  in  Fig.  120,  consists  of  a  smooth  block 
of  vulcanite,  or  of  a  shell  of  the  same  material,  which  exactly  fits 
and  fills  the  vagina,  and  has  an  opening  or  canal  running  through 
its  centre  which  receives  the  cervix  uteri.  It  passes  as  readily  into 
the  vagina,  when  greased,  as  the  cylindrical  speculum  does,  and  the 
cervix  slipping  into  its  canal  is  held  as  if  in  splints,  and  thus  bent 
backwards.  There  is  no  other  pessary  with  which  I  am  acquainted 
that  performs  this  function  so  well.  It  answers  excellently  in  all 
cases,  except  those  which  belong  to  a  most  incurable  class  of  ante- 
fiexions,  namely,  in  those  where  the  vagina  joins  the  cervix  very 
near  the  os  externum.  In  these  the  cervix  cannot  project  into 
the  canal,  and  hence  the  sjplint-like  action  of  the  instrument  is 
not  developed.    '  There  is  one  precaution  to  be  ol)served  in  refer- 


408  ANTEFLEXION. 

euce  to  Kurd's  pessary ;  if  the  instrument  employed  be  too  small, 
the  cervix  may  be  incarcerated.  There  are  three  sizes  of  the 
instrument,  and  a  proper  one  should  be  selected.  In  all  cases,  too, 
it  should  be  carefully  watched  during  its  retention  in  the  vagina. 

Fig.  120.  Fig-  121. 


Hurd's  pessary  ;  uterus  not  yet  placed  in  it.  Hurd's  pessary  ;  uterus  in  position. 

that  this  accident  may  be  avoided.  There  are  two  entirely  diiferent 
forms  of  Hurd's  pessary,  with  reference  to  the  course  of  the  central 
canal.  In  that  intended  for  anteflexion,  the  canal  runs  as  shown 
in  the  figure ;  in  that  for  retroflexion  and  retroversion,  it  inclines 
directly  forwards. 

In  these  cases  I  employ,  also,  an  instrument  shaped  exactly  like 
that  shown  in  Fig.  95,  except  that  the  anterior  movable  piece 
consists  of  a  solid  disk  or  plate.  Against  this  the  flexed  neck  and 
body  rest  as  against  a  splint  or  board,  and  by  it  the  bent  wall  is 
straightened. 

He  who  expects  from  these  methods  remarkably  satisfactory 
results,  will  surely  be  disappointed.  In  a  certain  number  of  cases 
failure  will  attend  all  means  thus  far  devised,  not  excepting  surgical 
procedures.  My  experience,  however,  warrants  me  in  saying  that 
a  persevering  resort  to  the  treatment  here  advised,  will  reward  the 
gynecologist  by  success  in  many  cases.  After  overcoming  this  form 
of  flexion,  a  Meigs's  ring  pessary  should  be  worn  for  a  long  time  to 
prevent  the  upward  and  forward  pressure  of  the  vagina.  After 
overcoming  this,  and  all  other  forms  of  flexion,  it  is  well  to  dilate 
the  cervical  canal  by  means  of  graduated  sounds,  as  there  is  gene- 
rally more  or  less  contraction  of  it. 

Irreducible  Flexion^  yieek,  hody^  or  hoth^  immovably  bent  forv)ards. — 
It  matters  not  which  of  these  three  varieties  of  irreducible*  flexion 

'  In  speaking  of  a  uterine  flexion  as  being  "  irreducible,"  the  term  must  be  un- 
derstood as  beincT  used  relatively  only.  The  uterine  tissue  is  elastic,  and,  of  course, 
always  yields  to  force. 


TREATMENT.  409 

we  meet  with,  it  is  incurable  except  by  two  means :  the  use  of  the 
intra-uterine  stem  or  the  knife.  These  cases  are,  I  think,  very 
commonly  congenital,  and  one  wall  is  well  developed  by  excessive 
growth,  while  the  other  is  dense,  rigid,  atrophic,  and  unyielding. 
It  may,  however,  result  from  prolonged  accidental  flexion,  with 
development  of  slight  attacks  of  peritonitis ;  even  without  the 
last,  indeed,  for  cicatricial  retraction  of  the  atrophied  section  of 
connective  tissue  has  been  found  by  Klob  in  such  cases. 

Recognizing  our  poverty  of  resources  in  certain  cases  of  version, 
M.  Velpeau,^  between  thirty  and  forty  years  ago,  conceived  the 
very  plausible  idea  of  restoring  the  uterine  axis  to  its  normal  direc- 
tion, by  introducing  a  stem  to  the  fundus,  and  retaining  it  there. 
After  experiment  he  abandoned  it,  and  subsequently  Amussat 
followed  in  his  steps,  both  in  essaying  and  casting  it  aside.  In 
1848,  Prof.  Simpson  again  brought  it  into  notice  in  versions  and 
flexions,  and  met  with  a  warm  ally  in  M.  Valleix,  of  Paris.  The 
instrument  known  as  the  intra-uterine,  or  stem  pessary,  unques- 
tionably counteracts  directly  and  immediately  all  flexions  of  the 
uterus.  But  it  was  found  to  cause  peritonitis  and  death  in  a  number 
of  instances,  and  in  consequence  it  was,  for  a  time,  almost  entirely 
abandoned.  So  decidedly  did  experience  appear  to  weigh  against 
it  that  it  became  difficult  to  explain  the  encomiums  once  showered 
upon  it  by  its  advocates,  and  the  remarkable  cures  reported  from 
its  use.  Nonat  declared  that,  carried  away  by  enthusiasm,  "  ils  se 
sont  laisses  aller  trop  lacilement  sur  le  terrain  glissant  des  illusions." 
^Nevertheless,  the  method  was  never  entirely  cast  aside,  for  none 
could  hesitate  to  indorse  the  sentiment  expressed  by  Malgaigne, 
in  the  discussion  upon  the  subject  in  the  Academy  of  Medicine  in 
Paris,  in  1852,  that,  "  a  treatment  which  Amussat,  Velpeau,  Simp- 
son, Huguier,  and  Valleix  had  tried,  cannot,  should  not,  be  con- 
sidered as  repugnant  to  common  sense." 

During  the  last  five  years  there  has  been  evidenced,  however,  a 
growing  inclination  to  return  to  this  plan,  and  the  last  year  has 
brought  forth  a  number  of  reports  favorable  to  it. 

At  a  medical  convention  held  in  Innsbruch,  Germany,  in  Sei> 
tember,  1869,  this  subject  received  some  attention.  Spteth,  of 
Vienna,  expressed  his  belief  in  the  disadvantages  of  the  intra- 
uterine treatment  of  flexions,  although  he  has  found  in  some  cases 
a  total  insensibility  and  an  absence  of  reaction  from  the  wearing 
of  intra-uterine   instruments.      Hugenberger,   of  St.    Petersburg, 

'*  Discussion  in  Acad.  <ie  Med.,  reported  in  Charleston  Med.  Journ.,  1853, 


410  ANTEFLEXION. 

advocated  the  use  of  Simpson's  pessary  in  flexions,  and  declared 
his  experience  to  be,  that  it  was  not  only  tolerated,  but  did  great 
good  when  projjerly  applied  and  retained  for  a  sufficiently  long 
time.  More  recently.  Prof  Schultze,  of  Jena,  advises  the  use  of  the 
intra-uterine  stem  in  certain  obstinate  cases,  but,  in  a  review  of  his 
publication,  by  Dr.  Munde,  in  the  American  Journal  of  Obstetrics, 
for  August  of  this  year,  it  evidently  appears  that  he  does  so  with 
caution  and  reserve. 

Prof.  Olshausen,  of  Halle,  likewise  publishes  his  recent  experi- 
ence with  the  method.  Of  its  character  the  reader  can  judge  for 
himself,  for  the  professor  gives  accurate  data.  Out  of  297  cases  of 
versions  and  flexions,  81  were  treated  by  the  stem  and  5  were  so 
treated  for  other  conditions  than  displacement.  Periuterine  inflam- 
mation resulted  in  7  cases;  treatment  was  stopped  on  account  of 
hemorrhage  or  pain  10  times ;  the  stem  could  not  be  kept  in  place 
3  times.  Of  66  cases  in  which  they  did  well,  in  15  the  results 
appeared  to  be  permanent;  in  18  improvement  was  great  and  lasted 
a  long  time;  and  in  17  "doubtful  permanent  results  were  obtained." 
In  11  sterility  was  cured.  Tlie  stems  were  worn  for  periods  vary- 
ing from  a  few  weeks  to  22|  months. 

Drs.  Thomas  Savage  and  Thomas  Chambers  have  both  reported 
very  favorably  ui)on  this  plan  in  the  Obstetrical  Journal  of  Great 
Britain  and  Ireland,  to  which  the  reader  is  referred  for  their 
interesting  articles. 

Before  the  use  of  this  method  careful  examination  should  be 
made  as  to  the  previous  existence  of  periuterine  inflammation.  If 
any  be  found  existing  the  uterine  stem  should  be  entirely  cast  aside. 

A  great  variety  of  instruments  has  been  employed  for  keeping  the 
stem  in  place.  Some  are  complicated,  others  stifl:'  and  unyielding, 
while  most  are  not  susceptible  of  removal  by  the  patient,  and  are 
therefore  wanting  in  the  main  element  of  safety.  I  would  recom- 
mend the  instrument  which  I  employ  for  this  purpose  as  not  subject 
to  any  of  these  objections.  It  consists  of  two  parts,  a  stem  of  solid 
glass  or  vulcanite,  two  to  two  and  a  half  inches  long,  and  ending 
below  in  a  round  bulb  as  represented  in  Fig.  122.  This  being  in- 
troduced into  the  uterus  is  supported  by  an  ordinary  anteflexion 
pessary,  between  the  branches  of  which  a  shallow  vulcanite  cup  has 
been  fixed,  with  a  small  hole  in  it  for  drainage. 

It  will  be  seen  that  the  support  of  the  uterus  is  not  intrusted  to 
the  intra-uterine  stem  alone.  It  is  in  part  eft'ected  by  the  pessary, 
and  the  stem  merely  serves  to  render  the  action  of  this  more  perfect 
than  it  would  otherwise  be. 


TREATMENT. 


411 


The  stem  ending  m  a  round  bulb  rests  in  the  cup  where  it 
changes  position  with  every  movement  of  the  uterus.  It  must  be 
remembered  that  it  is  not  used  for  anteversion  but  for  anteflexion, 
and  that  stability  of  the  base  of  the  stem  is  not  desirable.     Just 


Fiff.  122. 


Intra-uterine  stem  and  pessary  for  anteflexion. 

above  the  shoulder  a  small  hole  is  drilled  through  the  stem  through 
which  a  silk  thread  is  passed  which  hangs  from  the  vulva.  Upon 
the  first  evidence  of  trouble  the  patient  draws  out  the  loosely  fitting 
pessar}',  then  making  traction  upon  the  thread  removes  the  stem. 

Before  introduction  of  the  stem,  the  cervix,  if  found  to  be  too 
contracted  for  it  to  pass,  should  be  dilated  by  one  or  more  sea-tangle 
tents,  which  for  the  time  straighten  the  uterus  and  dilate  the  cer- 
vical canal.  After  introduction  the  patient  should  be  kept  in  bed 
for  three  or  four  days,  and  upon  leaving  it,  should  be  careful  in  her 
movements  for  a  week  or  two.  During  menstruation,  the  instru- 
ment should  be  removed,  and  during  the  non-menstrual  period,  she 
should  be  directed  to  remove  it  at  once  upon  the  occurrence  of 
pain,  chilliness,  or  feeling  of  general  languor  or  discomfort.  Even 
the  most  ardent  advocates  of  stem  pessaries  will  admit  the  propriety 
of  these  precautions,  and  even  their  bitterest  opponents  must  allow 
that  with  them  as  a  safeguard,  in  certain  cases  they  should  be 
resorted  to.  To  cast  them  entirely  aside  when  such  high  authority 
recommends  them,  would  be  irrational  and  unjustifiable.  To  use 
them  freely  in  the  face  of  such  evidence  as  we  possess  would  be 
reckless  and  unwarrantable. 

Should  the  patient  not  tolerate  the  intra-uterine  pessary  with 
comfort,  should  the  flexion  not  yield  to  the  treatment  by  it,  or, 
should  the  practitioner  prefer  to  adopt  operative  procedures,  an 
operation  is  at  his  disposal  not  intended  to  cure  the  displacement, 


412 


ANTEFLEXION. 


but  to  remedy  its  resulting  cervical  obstruction,  leaving  the  disorder 
of  position  unchanged. 

Operation  for  Irreducible  Cervical,  Corpoi^eal,  or  Cervico-Corporeal 
Flexion.— If  a  piece  of  stiff  tubing  be  bent,  the  calibre  of  its  canal 
will  be  obliterated  at  the  point  of  flexure  in  proportion  to  the 
acuteness  of  the  angle  created.  In  the  same  manner  is  the  uterine 
canal  affected  by  the  lesion  under  consideration.  The  obstruction 
created  in  this  v^^ay  prevents  the  free  escape  of  menstrual  blood, 
which  distends  the  cavity  of  the  uterus  and  forms  clots  within  it, 
and  these  at  each  menstrual  period  are  expelled  by  uterine  tenes- 
mus. In  consequence  of  this,  inflammation  of  the  mucous  lining 
of  the  uterus  arises,  that  in  time  may  produce  areolar  hyperplasia, 
which  favors  further  displacement  by  the  increase  of  uterine 
weight  attending  it.  The  eflbrt  required  for  expelling  clotted 
menstrual  blood  constitutes  painful  menstruation,  and  the  same 
obstruction  which  retards  egress  of  fluids  interferes  with  ingress 
and  prevents  conception. 

Having  been  forced  to  accept  the  displacement  as  an  irremedi- 
able evil,  we  now  endeavor  to  strike  at  the  source  of  the  pathologi- 
cal series  which  results  from  it  by  overcoming  obstruction  at  the 
point  of  flexure;  in  other  words,  by  substituting  a  straight  for  a 

crooked  canal.  This  can  be  accom- 
plished by  cutting  through  one  or  both 
walls  of  the  cervix.  Having  thus  over- 
come cervical  obstruction  and  conse- 
quent accumulation  of  fluids  in  utero, 
do  we  at  the  same  time  remove  the 
tendency  to  mechanical  congestion  of 
the  body  of  the  uterus  ?  Not  entirely, 
but  if  we  secure  the  results  of  cervical 
section  as  we  should  ordinarily  do  by 
subsequent  use  of  the  intra-uterine 
stem,  we  accomplish  to  a  certain  extent 
both  results. 

If  the  posterior  uterine  wall,  bent  for- 
ward as  shown  by  the  line  c  6,  Fig.  123, 
in  a  case  of  anteflexion,  be  cut  towards 
the  vaginal  junction  so  that  a  probe 
will  pass  into  the  uterus  in  the  direc- 
tion of  the  line  a  d,  the  obstruction 
resulting  from  the  existence  of  an  angle 
will  be  removed,  and  thus  fluids  would 


Fig.  123. . 


•  •    or 

Creation  of  new  uterine  axis. 
a  b  represents  the  axis  of  the  body  ; 
b  c  represents  the  axis  of  the  neck  ; 
b  d  represents  the  axis  created  by 
incision. 


TREATMENT. 


413 


have  free  entrance  and  exit,  for  instead  of  turning  the  angle  at  b 
and  escaping  at  c,  they  would  at  once  escape  at  6. 

The  operation  which  accomplishes  this  result  is  an  exceedingly 
simple  one,  and  is  thus  performed.  The  patient  being  placed  in 
position,  and  Sims's  speculum  introduced,  the  cervix  is  seized  and 
held  firmly  by  a  tenaculum.  Then,  by  means  of  a  pair  of  long- 
handled  scissors,  an  incision  is  made  as  far  as  can  be  conveniently 
done  without  involving  the  vaginal  junction,  which  will  probably 
be  below  the  point  b  in  Fig.  123,  The  blade  of  Sims's  knife,  re- 
presented in  Fig.  124,  is  now  introduced  through  the  os  inter- 


Fig.  124. 


Siins's  knife. 


num,  and  the  tissues  are  cut  so  as  to  lay  open  the  posterior  wall  of 
the  cervix.  A  little  shoulder  will,  as  Dr.  Emmet  has  pointed  out, 
be  generally  found  to  exist  on  the  anterior  wall  of  the  canal,  just 
at  the  angle  made  by  flexure  of  this  wall.  Towards  this  the  blade 
of  the  knife  should  now  be  turned,  and  it  should  be  cut  through. 


Fig.  125. 


Posterior  section  of  the  cervix.     (Sims.) 

In  this  operation  the  scissors  and  knife  alone  should  be  used. 
None  of  the  uterotomes  are  at  all  appropriate.  Just  after  the  ope- 
ration a  roll  of  cotton  saturated  with  solution  of  persulphate  of 


414  ANTEFLEXION. 

iron,  one-third  to  two  of  water,  should  be  introduced  so  as  to  occupy 
the  whole  cervix  from  os  internum  to  os  externum.  Under  this 
a  firm  tampon  of  wet  cotton  should  be  placed.  In  twenty-four  or 
thirty-six  hours  the  tampon  should  be  removed,  but  the  roll  within 
the  cervix  may  be  left  for  three  or  four  days.  After  this  it  should 
be  renewed  two  or  three  times  to  secure  complete  perviousness  of 
the  canal.  In  three  or  four  weeks  the  intra-uterine  stem  may  be 
introduced  and  worn  if  its  use  be  deemed  advisable. 

Should  an  error  be  made  as  to  the  etiology  of  the  displacement 
or  the  recognition  of  its  complications,  and  this  apparently  trifling 
operation  be  performed  during  the  existence  of  periuterine  cellu- 
litis or  peritonitis,  the  gravest  results  may  follow,  and  the  suffer- 
ings of  the  patient  be  greatly  aggravated.  Indeed,  had  all  the 
fatal  cases  which  have  occurred  in  consequence  of  this  oj^eration 
been  published  to  the  profession,  as  they  should  have  been,  the  list 
would,  I  think,  be  a  startling  one.  I  myself  know  of  five,  and 
have  heard  rumors  of  others.  It  may  be  asked  why  this  opera- 
tion upon  a  part  of  the  uterus  which  does  not  ordinarily  resent 
surgical  interference  should  so  often  be  followed  by  dangerous 
consequences.  My  conviction  is,  that  the  operation  jjer  se  is  not 
attended  by  great  danger.  It  is  the  performance  of  it  when 
pelvic  peritonitis  exists  in  chronic  form  that  has  caused  it  to 
produce  such  bad  results.  Even  a  minor  oj)eration,  performed  in 
the  face  of  a  condition  which  should  interdict  the  use  of  the  uterine 
probe,  may  set  up  a  train  of  symptoms  which  may  lead  to  a  fatal 
issue. 

I  have  so  often  found  the  slit  in  the  posterior  wall,  made  after 
Sims's  method,  which  has  just  been  described,  heal  up  for  a  great 
part  of  its  extent  some  months  after  the  patient  has  passed  out  of 
observation,  that  I  now  resort  to  a  different  procedure.  By  means 
of  the  double  scissors  represented  in  Fig.  126, 1  cut  by  one  stroke 

Fig.  126. 


a  strip  of  tissue  one-quarter  of  an  inch  wide,  and  extending  from 
the  08  externum  to  the  vaginal  junction.  Having  removed  this  I 
then  cut  by  the  same  instrument  a  small  piece  out  of  the  upper 
extremity  of  the  incision,  as  the  instrument  always  slips  down- 
wards a  little  and  fails  to  cut  as  high  as  is  desirable.     Then  the 


EETROFLEXION.  '  415 

knife  should  be  slid  up  and  tlie  projecting  points  of  tissue  cut  as 
shown  in  Fig.  125,  so  as  to  make  a  straight  and  unobstructed  canal. 
Should  there  be  any  difficulty  in  introducing  one  blade  of  this  in- 
strument into  the  cervix,  snipping  the  os  externum  with  scissors 
^\'ill  remove  it.  By  this  means  I  have  obtained  much  more  perma- 
nent results  than  by  the  single  incision.  Dr.  Nott  went  further 
than  this,  and  in  these  cases  removed  the  entire  posterior  wall  of 
the  cervix,  as  near  as  possible  to  the  utero- vaginal  junction. 

After  these  procedures  for  the  cure  of  anteflexion  which  has  for 
a  long  time  been  irreducible  and  was  very  probably  congenital, 
conception  is  by  no  means  common.  Operations  for  this  condition 
often  effect  relief  of  menstrual  and  amelioration  of  circulatory 
disorders ;  and  they  may  even  cure  sterility,  but  he  who  practises 
them  should  beware  how  he  makes  promises  to  this  effect. 


CHAPTER   XXV. 

RETROFLEXION. 

Definition. — Retroflexion  is  said  to  exist  when  the  body  of  the 
uterus  is  bent  towards  the  sacrum  so  as  to  create  an  angle  on  the 
posterior  wall. 

Varieties. — This  displacement  has  been  divided  into  varieties 
dependent  upon  the  degree  of  intensity.  These  are  so  entirely 
arbitrary  that  they  may  as  well  be  ignored. 

SymjJtoms. — Retroflexion  produces  annoying  symptoms  by  cre- 
ating congestion  of  the  uterine  body,  obstructing  the  cervical  canal, 
and  causing  pressure  on  the  rectum,  congestion  of  the  ovaries,  and 
reflex  nervous  manifestations.  Through  so  many  avenues  of 
approach  it  may  well  be  supposed  that  its  symptoms  are  numerous. 
They  are  usually  as  follows: 

Severe  backache; 

"Weight  in  rectum  with  tenesmus; 

Leucorrhoea ;  * 

Bysmenorrhoea ; 

Nervous  disturbances ; 

Difiicult  locomotion;  » 

Menorrhagia ; 


416  EETPvOFLEXIOISr. 

Tendency  to  abortion; 
Pain  on  sexual  intercourse; 
Pelvic  neuralgia; 
Epigastric  depression ; 
Gastric  derangement ; 
Uterine  colic  or  tenesmus ; 
Sterility. 

Many  of  these  symptoms  produce  epiphenomena  of  their  own,  and 
thus  increase  a  list  which  is  already  long. 

Physical  Signs. — The  diagnosis  is  made  by  the  following  means: 

Vaginal  touch ; 
Conjoined  manipulation; 
Rectal  touch ; 
The  uterine  probe. 

The  patient  lying  on  the  back,  the  index  finger  is  introduced  to 
the  cervix,  which  is  found  in  its  normal  place.  It  is  then  swept 
over  the  base  of  the  bladder,  where  nothing  abnormal  is  observed. 
Then  it  is  passed  into  the  fornix  vaginae,  and  here  a  round  tumor 
continuous  with  the  ridge  of  the  cervix  is  discovered.  The  disen- 
gaged hand  is  then  placed  on  the  abdomen,  and  made  to  approxi- 
mate the  finger  in  the  vagina,  so  as  to  grasp  the  body  of  the  uterus. 
If  the  abdominal  walls  be  lax,  this  will  yield  good  results,  but  not 
otherwise.  The  finger  should  now  be  carried  into  the  rectum,  in 
order  to  study  further  the  character  of  the  tumor  pressing  upon 
this  canal.  The  patient  being  then  placed  ujion  her  side  and  the 
speculum  introduced,  the  uterine  probe,  which  has  been  curved  in 
accordance  with  the  direction  impressed  on  the  mind  by  the  sense 
of  touch,  is  gently  passed  into  the  uterine  cavity  to  the  fundus, 
which  completes  the  diagnosis. 

Differentiation. — Retroflexion  may  be  confounded  with  fecal  im- 
paction, fibrous  tumors,  cellulitis  or  peritonitis,  a  prolapsed  and 
enlarged  ovary,  and  prolapsed  kidney.  The  careful  practice  of  the 
four  diagnostic  methods  mentioned,  will  remove  all  doubt. 

In  certain  very  rare  cases  the  kidney  has  been  known  to  prolapse 
into  Douglas's  cul-de-sac  and  produce  the  most  anomalous  symi)toms. 
In  a  case  of  my  own  in  Avhich  a  very  obscure  tumor  existed  pos- 
terior to  tlie  uterus,  this  diagnosis  was  made  by  Dr.  Is"oeggerath  in 
consultation.  In  accordance  with  his  advice  1  placed  the  patient 
in  the  knee-chest  position,  and  applied  a  good  deal  of  upward 
pressure,  when  the  tumor  suddenly  escaped  into  the  abdomen. 
Support  was  given  by  a  bulb  pessary,  and  for  a  time  my  patient 


CONSEQUENCES  OF  RETROFLEXION,  417 

was  relieved,  but  upon  licr  return  to  lier  home  in  Virginia  a  com- 
plete relapse  occurred.  Dr.  Noeggerath  tells  me  that  he  has  met 
with  but  one  other  such  case.  Of  course  the  correctness  of  the 
diagnosis  is  doubtful.  I  am  inclined  to  admit  it  from  the  peculiar 
symptoms  exhibited,  and  bj  the  fact  that  post-mortem  examina- 
tion proves  that  such  a  prolapse  of  a  floating  kidney  sometimes 
occurs.  The  following  account  of  such  a  case  may  be  found  in 
Braithwaite's  Retrospect.' 

"  Examining  the  body  of  a  man  who  had  died  of  phthisis,  aged  thirty- 
five,  Dr.  Isaacs  found  the  left  kidney  located  in  the  pelvis,  its  upper  end 
being  in  contact  with  the  bifurcation  of  the  aorta,  and  its  lower  touching 
the  posterior  surface  of  the  bladder,  and  lying  on  the  fifth  lumbar  ver- 
tebra, and  first,  second,  and  third  pieces  of  the  saci'um.  Its  right  edge 
was  in  contact  with  the  rectum,  and  the  left  with  the  iliac  portion  of  the 
brim  of  the  pelvis.  There  were  three  renal  arteries,  one  coming  from  the 
aorta,  and  two  others  from  the  right  common  iliac.  The  kidney  was  of 
the  ordinary  size,  but  the  supra-renal  caj)sule  was  twice  its  nntural  size, 
and  of  the  shape  of  a  fig-leaf,  and  it  occupied  its  normal  position  in  the 
lumbar  region." 

Consequences  of  Betroflexion. — The  post-uterine  peritoneal  space 
being  much  more  extensive  than  the  anterior,  retroflexion  proceeds 
to  a  more  aggravated  degree  than  anteflexion.  The  body  some- 
times descends  to  the  upper  extremity  of  the  vagina,  and  instances 
are  recorded  by  Rokitansky  and  Schott  in  which  it  has  penetrated 
the  walls  of  the  rectum  and  vagina,  and  forced  itself  into  these 
canals.  This  of  course  is  a  very  rare  occurrence,  but  it  is  worthy 
of  mention  as  showing  how  great  is  the  pressure  which  a  retroflexed 
uterus  may  exert.    The  ordinary  consequences  of  the  afteetloaare — 

Dysmenorrhoea ; 

Endometritis; 

Sterility; 

Areolar  hyperplasia; 

Pelvic  peritonitis. 

As  rare  complications  may  also  be  recorded,  hematometra  and 
hydrometra  from  imprisonment  of  fluids  b}^  obliteration  of  the  canal 
by  flexure  at  the  os  internum.  Should  pregnancy  occur  durino-  the 
existence  of  this  deviation,  or  retroflexion  complicate  pregnancy, 
and  the  fundus  be  incarcerated  below  the  promontory,  of  the  sa- 
crum, abortion  will  result.     This  cause  of  that  accident  is  so  very 


'  Am.  ed.,  Part  xxxvii,  p.  87, 

27 


418  RETROFLEXIOX. 

common  that  it  should  be  suspected  and  examined  for  in  every 
ease  of  habitual  abortion. 

Prognosis. — The  prognosis  is  always  good  in  retroflexion,  unless 
one  of  the  following  conditions  exists:  1st.  A  cervico- vaginal  j  unc- 
tion so  low  as  to  give  no  post-cervical  sjDace  for  accommodation  of  a 
pessary ;  2d.  The  previous  existence  of  peritonitis  and  fixation  of 
the  uterus ;  3d.  The  existence  on  the  posterior  wall  of  a  sensitive 
fibrous  tumor. 

Treatment  of  a  Case  of  Reducible  Retroflexion. — The  patient  should 
be  prepared  for  treatment  as  in  anteflexion.  To  avoid  re})etition,  I 
refer  the  reader  to  that  subject  for  details.  The  indications  are 
clearly  to  restore  the  retroflexed  organ  and  to  keep  it  in  normal 
position.  In  some  cases  attention  to  the  first  indication  is  all  that 
will  be  required,  for  retroflexion  is  sometimes  an  accident  occurring 
suddenly  from  violence.  Usually,  however,  both  indications  must 
be  fulfilled. 

In  replacing  the  flexed  part  no  great  degree  of  difiiculty  is  gene- 
rally experienced,  if  the  following  method,  which  I  would  strongly 
urge,  be  adoj^ted.  The  patient  being  placed  in  the  left  lateral 
position,  with  the  left  arm  drawn  behind  the  body,  the  operator 
lubricates  the  ring  and  middle  fingers  of  his  right  hand  and  passes 
them  with  palmar  surfaces  towards  the  posterior  vaginal  wall  up 
to  the  fundus.  He  now  stands  behind  the  patient,  his  face  looking 
towards  lier  occiput,  and  the  line  of  the  anterior  surface  of  his  body 
being  about  on  a  level  with  one  passing  through  the  woman's  body 
at  the  base  of  the  sacrum.  Now  bending  forwards,  he  b}'  the 
tips  of  the  fingers  pushes  the  fundus  upwards,  while  by  their  bases 
he  retracts  the  perineum,  elevates  the  posterior  vaginal  wall,  and 
admits  air  freely  to  the  vagina.  As  the  uterine  body  rises  in  the 
pelvis  to  a  perpendicular,  the  flat  surface  of  the  finger-nails  will 
rest  against  it.  By  these  he  makes  pressure  forwards,  that  is, 
towards  the  pubes,  and  steadily  forces  the  uterus  into  anteflexion. 

I  am  thus  particular  in  describing  this  manoeuvre,  because  I 
regard  it  as  an  improvement  upon  the  ordinary  ones  for  overcom- 
ing this  and  other  posterior  displacements,  and  would  ask  for  it  a 
trial,  and  not  a  judgment  upon  theoretical  grounds  alone.  My 
impression  is  that  the  position  of  the  operator  enabling  him  to 
push  the  perineal  border  towards  the  coccyx,  considerable  addi- 
tional space  is  gained,  and  the  fingers  reach  a  higher  point  than 
they  could  otherwise  be  made  to  do. 

In  very  difiicult  cases,  the  knee-chest  position  may  be  necessary, 
but  it  is  not  often  called  for. 


TREATMENT. 


419 


After  replacement,  has  been  effected  in  this  way,  the  sound  may 
be  emi3loyed  to  make  sure  of  its  thoroughness  and  to  increase  it. 
Should  it  be  used  before  manual  replacement,  it  should  be  done 
very  cautiously  and  by  the  following  steps: 

1st.  It  should  be  introduced,  but  slightly  bent,  to  the  fundus. 

2d.  Holding  the  handle  in  his  left  hand,  the  operator  should 
place  the  tips  of  the  fingers  of  the  right  hand  upon  the  shaft  and 
carry  it  towards  the  perineum  as  far  as  possible. 

3d.  The  uterus  being  now  to  a  certain  degree  straightened  and 
elevated,  the  sound  should  be  rotated  so  as  to  throw  the  fundus 
forwards,  and  the  handle  of  the  instrument  held  in  one  hand  be 
carried  towards  the  patient's  back  so  as  to  advance  the  tip  as  far  as 
possible  towards  the  abdominal  walls. 

Reading  a  procedure  thus  described  often  leaves  the  impression 
that  it  is  a  complicated  one,  and,  perhaps,  that  the  directions  given 
are  unimportant.  Let  one  who  has  habitually  used  the  sound 
simply  as  a  rotator  fairly  try  this  more  delicate  and  rational 
employment  of  it,  and  I  am  sure  that  he  will  adhere  to  it,  even 
although  prejudiced  against  it  originally. 

Sims's  repositor,  likewise,  answers  very  well  in  cases  of  retro- 
flexion after  partial  replacement  by  the  fingers. 

When  it  is  proposed  to  sustain  the  flexed  organ,  all  weight 
should  be  removed  from  the  hips  by  a  skirt  supporter,  tight  dress- 
ing prohibited,  and  the  patient  cautioned  against  all  muscular 
efforts,  but   confinement   to   bed   is   at   no  time  necessary.     The 

Fig.  127. 


Thomas's  retroflexion  pessary. 

fibdominal  walls,  if  lax,  should  be  strengthened  by  an  abdominal 
supporter,  and  a  pessary  adjusted  so  as  to  give  direct  support  to  the 
displaced  part.  Should  no  excessive  tenderness  exist  the  pessary 
shown  in  Fig.  127  will  answer  excellently.  I  employ  it  more  com- 
monly than  any  other  in  these  cases.     It  is  narrow,  measuring  be- 


420  RETROFLEXION. 

tween  its  branches  at  the  widest  part  seven-eighths  of  an  inch  in 
the  smallest  sizes,  and  one  and  one-eighth  of  an  inch  in  the  largest ; 
upon  its  upper  extremity  is  a  bulb  which  prevents  cutting  of  the 
tissues;  its  lower  extremity  rests  against  the  tissues  under  the 
pubes;  and  it  is  five  inches  long  in  the  largest  sizes,  and  four  and 
a  quarter  in  the  smallest,  measured  along  tlie  outside  curve  of  the 
branches.  Spanning  the  pelvis,  this  narrow  instrument  stretches 
the  vagina  without  distending  it,  and  pushes  the  fundus  to  a  higher 
point  than  any  other  with  which  I  am  familiar.  Its  retention 
depends  not  upon  its  size  but  its  relation  to  the  pelvis,  for  it  is 
prevented  from  escaping  not  by  separation  of  its  branches,  hut  by 
the  length  and  degree  of  the  post-uterine  curve,  and  by  the  re- 
tention established  by  the  tissues  under  the  pubes  against  the  down- 
ward curved  lower  extremity. 

In  place  of  this,  any  one  of  the  pessaries  mentioned  under  the 
head  of  treatment  of  retroversion  may  be  employed,  as,  for  example, 
Hodge's,  Albert  Smith's,  or  Hewitt's. 

If  the  fundus  be  light  and  easily  reduciljle,  one  of  these  will 
answer  the  purpose ;  but,  if  it  be  heavy  or  rebellious  to  reduction, 
Cutter's  pessary  with  the  bulb.  Fig.  Ill,  answers  a  much  better 
purpose.  Fitted  accurately,  and  worn  by  a  patient  wliose  waist 
is  kept  free  from  constriction,  and  licr  abdomen  from  pressure,  it 
not  only  sustains  a  reducible  uterine  body,  but  I  have  frequently 
seen  it  replace  one  which  was  irreducible  by  other  means. 

By  these  means  a  uterus  affected  by  a  reducible  retroflexion 
may,  in  all  conditions  excepting  two  unfavoral)le  ones  already 
mentioned,  be  restored  to  its  place  and  kept  there  without  resort 
to  the  intra-uterine  stem  or  a  cutting  operation.  These  unfavora- 
ble conditions  we  will  now  consider. 

"When  the  vagina  unites  itself  to  the  cervix  so  near  its  lowest 
point  as  to  leave  almost  no  post-cervical  space,  it  is  impossible  to 
sustain  the  uterus  by  any  vaginal  pessar3^  Under  these  circum- 
stances, and  these  alone,  I  believe  the  intra-nterine  stem  to  be 
necessary.  The  same  which  was  recommended  in  anteflexion  will 
answer  here ;  the  sustaining  instrument  being  a  small  retroversion 
pessary,  and  not  one  for  anteversion. 

Sometimes  the  posterior  uterine  wall  becomes  the  site  of  a  fibrous 
tumor,  which,  by  keeping  up  congestion  by  its  presence  as  well  as 
by  the  flexion  which  it  induces  or  aggravates,  renders  the  wliole 
fundus  so  tender,  that  an  ordinary  pessary  cannot  be  tolerated.  In 
such  cases  the  bulb  should  be  removed  from  the  modified  Cutter's 
pessary  and  replaced  by  a  soft  sponge,  and  by  this  the  uterus  be  sup- 


TREATMENT. 


421 


ported.      Sometimes    under   tliese   circumstances   Ilurd's   pessary, 
Fig.  128,  will  be  found  to  answer  a  good  purpose. 


Fig.  128. 


Fiff.  129. 


Hurd's  pessary. 


Eetroflexed  uterus  in  Hurd's  pessary. 


The  inflated,  soft  rubber  pessary  of  Hofl'man,  Fig.  108,  is  also 
a  serviceable  temporary  instrument  under  such  circumstances. 
Where  tenderness  is  excessive,  it  will  often  be  found  to  be  a  wiser 
course  to  pack  the  fornix  with  medicated  cotton  or  sponge,  and 
elevate  the  whole  uterus,  as  advised  in  treating  of  retroversion. 
By  employing  this  method  for  a  time,  a  pessary  will  soon  be 
tolerated. 

Treatment  of  Irreducible  Retroflexion. — Anteflexion  is  probably 
often  a  congenital  condition,  or  continues  for  so  long  a  period 
during  the  life  of  the  girl  before  it  is  discovered,  that  the  anterior 
inflexion  becomes  an  irreducible  uterine  deformity.  This  is  some- 
times, though  much  less  frequently  so  in  retroflexion,  which  is 
usually  reducible,  unless  the  flexed  body  be  bound  down  by  false 
membranes,  the  result  of  slight  peritonitis.  It  is  sometimes  diffi- 
cult in  a  given  case  to  decide  the  cause  of  the  permanency  of  the 
displacement.  In  a  general  way  it  may  be  said  that  if  it  be  due  to 
false  membranous  attachment,  the  uterus  will  not  move  from  its 
position  in  the  pelvis  ;  if  it  be  due  to  contraction  in  the  tissue  of 
the  uterus  itself,  the  organ  will  change  its  pelvic  relations,  but  not 
the  abnormal  ones  existing  between  body  and  neck. 

In  case  the  flexion  be  found  due  to  parenchymatous  alteration, 
no  surgical  procedure  should  be  adopted ;  but  the  body  should  be 
cautiously  bent  forwards  once  or  twice  a  week  by  means  of  the 
sound  or  repositor,  and  kept  in  anterior  inclination  by  means  of 
the  retroflexion  pessary,  shown  in  Fig.  127,  or  by  the  modified 
Cutter's  pessary. 


422 


RETROFLEXION. 


If  the  uterus  be  found  fixed  in  the  position  of  retroflexion  by 
false  membranous  attachments,  not  of  recent  origin,  and  tlie  jiatient 
be  not  suffering  to  such  an  extent  from  the  displacement  as  to 
render  reposition  urgently  necessary,  it  had  better  be  left  undis- 
turbed in  its  unnatural  place.  Should  the  disorder,  however,  be 
affecting  the  health,  or  causing  such  pain  and  discomfort  as  to 
render  the  incurring  of  the  risk  of  peritonitis  warrantable,  reduc- 
tion should  be  accomplished  in  this  way.  The  patient  having  been 
anoesthetized  and  placed  in  the  left  lateral  position,  the  sj)hincter 
ani  should  be  stretched  by  the  thumbs.  Then  the  index  and  middle 
fingers  of  the  right  hand  should  be  passed,  with  the  palmar  surfaces 
towards  the  sacrum,  up  the  rectum  to  the  flexed  uterine  body. 
Steady  pressure  should  then  be  made  upon  it  until  the  organ  is 
lifted  upright,  when,  the  fingers  being  made  to  describe  the  arc  of 
a  circle  towards  the  pubes,  the  outer  surfaces  of  the  finger-nails 
will  Ije  in  contact  with  the  uterine  body,  and  by  them  it  will  be 
j)ushed  over  into  an  anterior  position.  After  this  the  fornix  should 
be  filled  with  a  soft,  moist  sponge,  and  this  forced  up  so  as  to  sus- 
tain the  body  by  a  tampon  of  cotton  in  the  vagina.  The  patient 
should  be  kept  very  quiet,  and  all  pain  should  be  soothed  by  free 
use  of  opium,  as  a  preventive  of  peritonitis. 


Fig-.  130. 


Lateroflezion. 

Sometimes  the  uterus  is  flexed  to  the  right  or  left  side  as  a  con- 
sequence of  disease  of  its  proper  tissue  or  direct  jjressure.     This 

variety  of  displacement  rarely  attains 
to  such  a  degree,  however,  as  to  re- 
sult in  obstruction  of  the  uterine 
canal.  Its  chief  importance  is  con- 
nected with  diagnosis,  for  it  may 
readily  be  mistaken  for  periuterine 
inflammation  or  a  fibrous  tumor. 
The  practice  of  conjoined  manipula- 
tion and  the  use  of  the  uterine  probe 
will  always  settle  the  point. 

The  treatment  of  lateroflexion 
sliould  be  conducted  upon  precisely 
the  same  principles  which  guide  us 
in  reference  to  anteflexion  and  retro- 
flexion. Of  all  varieties  of  flexion 
this  is  the  most  likely  to  require  the  use  of  the  intra-uterine  stem, 
for  it  is  exceedingly  diflicult,  I  may  even  say  rarely  possible,  to 


INVERSION    OF    THE    UTERUS. 


423 


overcome  it  by  a  vaginal  instrument.  When  this  necessity  pre- 
sents itself,  either  in  retroflexion  or  lateroflexion,  I  employ  the 
intra-nterine  stem  represented  in  Fig.  130.  The  fundus  is  in  part 
sustained  by  the  pessary,  not  entirely  by  the  stem. 


CHAPTER   XXVI. 


INVERSION  OF  THE  UTERUS. 


Definition. — This  dangerous  and  infrequent  form  of  displacement 
consists  in  the  turning  of  the  uterus  inside  out.  As  the  bottom  of 
a  bag  may  be  pushed  through  its  mouth,  so  that  the  inner  surface 
becomes  the  outer,  so  may  that  of  the  uterus,  and  the  occurrence  of 
such  an  accident  constitutes  the  disease  which  we  are  considering. 

Varieties. — Writers  differ  in  classifying  the  varieties  of  the 
affection,  some  describing  three  and  some  four  forms.  For  prac- 
tical purposes  all  these  may  be  brought  under  two  heads — partial 
and  complete.  In  the  first  the  body  has  become  depressed,  but  has 
not  passed  through  the  os.  In  the  second  the  uterus  has  been 
turned  completely  inside  out,  and  the  inverted  fundus  and  body 


Fig.  131. 


Fiff. 132. 


Partial  iuveision. 


Complete  inversion. 


hang  in  the  vagina  or  between  the  thighs,  "  velut  scrotum,"  as  it 
has  been  expressed  by  Hippocrates.  Fig.  131  represents  the  first, 
and  Fig.  132  the  second  form  of  the  accident. 

In  addition  to  these  varieties  the  accident  must  be  divided  into 


424  INVERSION    OF    THE    UTERUS. 

acute  and  chronic,  or  sudden  and  gradual  inversion,  as  it  occurs 
rapidly  or  slowly. 

Anatomy.— In  treating  of  flexions  of  the  uterus,  it  vs^as  remarked 
that  they  are  chiefly  prevented  by  the  resisting  nature  of  the 
parenchyma  of  the  cervix  which  supports  the  fundus  and  body. 
A  similar  function  on  the  part  of  the  entire  uterine  structure  kee[.8 
the  cavities  of  the  neck  and  body  closed,  and  x»revent8  inversion. 
Should  that  power,  wdiich  in  the  pregnant  uterus  we  call  contrac- 
tility, and  in  the  non-pregnant,  tone,  be  to  any  great  degree  im- 
paired, the  body  of  the  organ,  bereft  of  support,  will  incline  for- 
wards or  backwards.  Should  it  be  entirely  abolished,  the  fundus 
under  the  influence  of  traction  or  downward  pressure  may  pass 
through  the  unresisting  os  and  escape  into  the  vagina,  constitut- 
ing inversion.  I  once  saw  this  perfectly  illustrated  in  a  cadaver 
upon  which  I  w^as  called  to  perform  version  soon  after  death.  As 
I  extracted  the  child  the  flaccid  uterus  followed  it  directly  and 
was  completely  inverted,  the  placenta  still  adhering. 

Pathology. — The  accident  depends  for  its  production  upon  two 
elements — 

1st.  Eelaxation  and  inertia  of  the  uterine  walls ; 
2d.  Downward  traction  or  pressure. 

The  first  of  these  may  be  a  primary  and  original  state,  or  it  may 
be  induced  by  the  second  after  months  of  exhausting  action.  For 
example,  after  labor  the  uterine  walls  may  remain  lax  and  atonic 
from  inherent  inertia ;  or  their  tissue  in  the  non-pregnant  state  may 
be  firm  and  resisting,  yet  in  time  be  overcome  by  the  traction  and 
dilatation  exerted  by  a  large  fibrous  polypus  attached  to  the  fundus. 

In  the  limited  space  which  1  can  allot  to  this  subject  it  is  im- 
possible to  present  the  various  theories  which  have  been  advanced 
for  the  explanation  of  the  mechanism  of  inversion ;  nor  would  it 
be  beneficial  for  the  student  that  I  should  do  so.  In  place  of  such 
an  efibrt  I  shall  mention  those  which  appear  to  me  to  possess  a 
really  important  and  practical  bearing  upon  the  subject. 

The  three  views  to  which  I  shall  direct  attention  are  the  fol- 
lowing: 

1st.  That  some  part  of  the  relaxed  body  prolapses,  and  passing- 
out  of  the  cervix  drags  the  entire  uterine  body  with  it. 

2d.  That  some  part  of  the  relaxed  body  prolapsing,  acts  as  an 
excitant  of  uterine  contraction  which  forces  the  remaining  portion 
through  the  cervix,  and  thus  inverts  the  whole  organ. 

3d.  That  lateral  traction  and  direct  pressure  on  a  cervix  the  tissue 


PATHOLOGY.  425 

of  whicli  is  abnormally  soft,  causes  eversion  of  this  part  and 
gradually  of  the  whole  uterus. 

The  first  of  these  is  the  oldest  and  even  at  present  the  most 
generally  received  view  as  to  the  mechanism  of  inversion.  Accord- 
ing to  it,  it  was  generally  supposed  that  the  part  of  the  fundus 
which  first  undergoes  inversion  is  the  middle.  This  is  denied  by 
Oldham  and  Kiwisch,  who  maintain  that  one  horn  first  inverts 
itself  and  is  followed  by  the  fundus,  the  other  horn,  and  then  the 
entire  body.  I  have  met  with  one  case  w^hicli  i;>roves  incontestably 
that,  even  if  this  be  not  a  rule,  inversion  at  least  occurs  in  this 
manner  sometimes.  A  patient  who  for  several  years  had  suffered 
from  menorrhagia,  applied  to  Prof.  C.  A.  Budd,  of  this  city,  for 
treatment.  Upon  examination  he  discovered  what  he  supposed  to 
be  a  fibrous  polypus  equal  in  size  to  a  hen's  egg  attached  to  the 
uterine  cavity  near  the  entrance  of  the  right  Fallopian  tube.  Care- 
fully differentiating  this,  as  he  supposed,  from  partial  inversion, 
he  applied  the  ecrascur  and  removed  it,  when  he  discovered  that 
he  had  removed  one  horn  of  the  uterus  with  a  part  of  the  corres- 
ponding Fallopian  tube  and  round  ligament.  The  case,  which  was 
one  of  partial  inversion,  was  not  susceptible  of  diagnosis.  The 
menorrhagia  attending  it  was  entirely  relieved  by  the  operation, 
the  patient  rapidly  recovering. 

When  the  accident  begins  in  this  way,  the  inverted  horn  pulls 
down  the  other  parts,  with  greater  or  less  rapidity,  and  thus  the 
method  of  occurrence  may  be  lost  sight  of.  Rokitansky,  in  speak- 
ing of  irregular  post-partum  uterine  contraction,  thus  describes 
partial  inversion,  with  which  he  has  tw^ice  met :  "  We  must  here 
mention  a  very  singular  circumstance  which  may,  on  account  of 
the  consequent  danger,  become  important,  and  may  even  be  mis- 
understood in  post-mortem  .examinations ;  it  is  paralysis  of  the 
placental  portion  of  the  uterus  occurring  at  the  same  time  that  the 
surrounding  parts  go  through  the  ordinary  processes  of  reduction. 
It  induces  a  very  peculiar  appearance.  The  part  which  gave  at- 
tachment to  the  placenta  is  forced  into  the  cavity  of  the  uterus  by 
the  contraction  of  the  surrounding  tissue,  so  as  to  project  in  the 
shape  of  a  conical  tumor,  and  a  slight  indentation  is  noticed  at  the 
corresponding  point  of  the  external  uterine  surface.  The  close  re- 
semblance of  the  paralyzed  segment  of  the  uterus  to  a  fibrous  poly- 
pus may  easily  induce  a  mistake  in  the  diagnosis,  and  nothing  but 
a  minute  examination  of  the  tissue  can  solve  the  question.  The 
affection  always  causes  hemorrhage,  which  lasts  for  several  weeks 
after  childbirth,  and  proves  fatal  by  the  consequent  exhaustion." 


426  INVERSION    OF    THE    UTERUS. 

Since  the  days  of  Astruc  tlie  theory  has  been  at  various  times 
maintained  that  active  contraction  of  the  uterus  sometimes  pro- 
duces inversion.  "  Sometimes,"  says  Astruc,  "  it  is  produced  from 
contraction  of  the  womb,  wliich  forces  the  bottom  inside  out, 
through  the  mouth  of  the  womb,  which  is  not  yet  closed."  Regu- 
lar uterine  contraction,  however  violent  it  may  be,  would  only 
tend  to  complete  closure  of  the  uterine  cavity.  If,  however,  such 
a  partial  inversion  or  internal  projection  as  that  alluded  to  by 
Rokitansky  in  the  quotation  recently  made,  occur,  it  acts  as  the 
placenta,  the  hand  of  the  obstetrician,  or  any  other  body  in  the 
cavity,  by  exciting  expulsive  efforts  wliich  may  succeed  in  driving 
it  out  of  the  OS  externum.  Should  they  do  so,  complete  inversion 
is  the  result ;  should  they  fail,  the  projection  may  persist  as  a  partial 
inversion.  This  view  which  was  advocated  by  the  late  Dr.  Tyler 
Smith  appears  to  me  to  explain  the  apparent  paradox  of  inversion 
with  tonic  contractions  of  the  uterus  more  satisfactorily  than  any 
other  which  has  been  advanced.  I  have  met  with  one  case  occur- 
ring after  delivery,  which  convinces  me,  that  sometimes,  at  least, 
what  I  have  just  described  really  takes  place. 

Still  another  and  very  ingenious  theory  has  been  advanced  by 
Prof.  I.  E.  Taylor  for  explaining  the  occurrence  of  inversion.  It  is 
that  inversion  sometimes  begins  at  the  cervix,  this  part  undergoing 
eversion  as  in  prolapsus,  and  this  going  on  to  the  comj^lete  inversion 
of  the  entire  organ. 

In  previous  literature,  allusions  to  the  possibility  of  inversion 
after  this  method  may  be  found.  Klob  alludes  to  it  in  these  words: 
"  A  very  remarkable  class  of  cases  of  inversion  are  those  in  which, 
without  efficient  cause,  an  inversion  of  the  cervix  into  the  vagina 
takes  place,  drawing  the  fornix  of  the  latter  with  it,  and  thus 
forming  a  polypus-like  tumor  in  the  cavity  of  the  vagina,  which 
may  reach  down  to  the  vulva,  at  the  lower  part  of  which  the 
internal  orifice  is  situated."  A  very  striking  case  was  published 
by  Mr.  William  Lawrence  in  the  London  Medical  Gazette,  Dec. 
5,  1838,  under  the  head  of  "Spontaneous  Partial  Inversion  of  the 
Uterus."  But  the  credit  of  having  drawn  proper  attention  to  the 
subject  and  having  proclaimed  its  probable  pathological  bearings, 
unquestionably  belongs  to  Taylor.  I  say  "  probable,"  for  the  reason 
that  it  is  not  yet  proved.  I  accept  it,  because  my  own  observation 
leads  me  to  believe  that  Dr.  Taylor's  deductions  are  probably  correct. 

Predisposing  Causes. — Every  influence  which  destroys  the  tone 
and  resistance  of  the  uterine  parenchyma  proves  a  predisposing 
cause  of  this  condition.     As  examples,  may  be  mentioned : 


EXCITi:XG    CAUSES.  427 

Parturition ; 

Distention  of  uterus  by  retained  fluids ; 

Distention  of  uterus  by  tumors ; 

Spongy  softening  of  tissue  in  prolapsus  (?), 

Exciting  Causes. — A  uterus  in  which  the  tone  of  the  walls  has 
been  destroyed  by  physiological,  pathological,  or  mechanical  causes 
has  lost  all  its  normal  safeguards  against  inversion.  Thus,  we  may 
say,  that  anything  which  produces  distention  and  relaxation  of  the 
tissue  of  the  uterus  prepares  the  way  for  inversion  so  comj)letely 
that  a  very  trifling  exciting  cause  may  produce  it.  For  example, 
any  decided  traction  or  pressure  exerted  upon  the  fundus  of  a  uterus 
thus  aflFected,  even  to  a  limited  degree,  may  directly  result  in  it. 
The  exciting  causes  are  thus  presented: 

Traction  on  placenta; 
Traction  by  polypi  or  tumors ; 
Sudden  delivery  of  child  by  traction ; 
Muscular  eftbrts  when  relaxation  exists ; 
Prolapsus  uteri  (?). 

Instances  of  its  production  by  all  these  causes  are  on  record, 
though  by  far  the  greatest  number  of  cases  has  followed  parturition. 
Of  400  cases  collected  by  Dr.  Crosse,  of  Norwich,  England,  350  fol- 
lowed delivery,  and  of  the  remaining  50,  forty  were  due  to  polypi. 
This  disproportionate  frequency  does  not,  however,  invalidate  the 
fact  that  the  other  causes  mentioned  have  resulted  and  may  result 
in  the  accident.  Most  frequently  it  occurs  very  soon  after  delivery, 
though  Ane  and  Baudelocque  report  its  having  taken  plac^e  on  the 
third,  and  Leblanc  on  the  tenth  day. 

Traction  and  relaxation,  when  combined,  are  evidently  sufiicient 
for  the  induction  of  the  accident,  and  it  is  generally  to  a  union  of 
the  two  that  it  is  due.  The  question  now  arises  whether  either  of 
them  alone  can  cause  it.  With  reference  to  the  efficiency  of  the 
second  element,  the  answer  may  be  affirmative,  since,  with  complete 
relaxation,  inversion  may  occur  from  a  very  insignificant  exciting 
cause,  as  coughing,  sneezing,  or  a  change  of  posture.  As  to  the 
possibility  of  any  amount  of  force  inverting  tlie  non-pregnant  and 
undilated  uterus,  much  doubt  has  been  expressed.  At  first  thought 
every  one  will  feel  inclined  to  express  a  decidedly  negative  opinion, 
but  the  evidence  on  record  in  favor  of  such  a  possibility  is  too 
strong  to  be  entirely  ignored.  A  portion  of  it  is  therefore  laid 
before  the  reader. 


428  INVERSION    OF    THE    UTERUS. 

Puzos/  in  1744,  read  before  the  Academy  of  Medicine  of  Paris 
a  memoir  in  which  he  declared  that  he  had  seen  the  accident  in 
women  who  had  never  borne  children,  Bojer^  cites  a  similar  ex- 
ample in  a  female  whose  uterus  contained  no  foreign  body,  and 
Daillez^  tells  us  that  Baudelocque  met  with  a  case  in  a  girl  fifteen 
years  of  age,  in  whom  clandestine  delivery  could  not  have  occurred, 
since  a  perfect  hymen  existed. 

Prof.  Willard  Parker,  of  New  York,  furnishes  me  with  the  his- 
tory of  the  following  case,  A  young  woman  who  had  borne  one 
child,  seven  or  eight  years  previously,  and  had  never  had  any  recog- 
nized uterine  disease,  while  making  a  violent  effort  in  rolling  ten- 
pins, suddenly  felt  something  give  way  within  her,  after  which  she 
sufi'ered  the  most  intense  pain  and  became  completely  disabled.  Dr. 
Parker,  being  called  to  see  her,  after  a  hasty  examination  coincided 
with  the  opinion  of  the  attending  physician,  that  a  polypus  had 
been  suddenly  expelled  and  was  hanging  in  the  vagina.  Impressed 
with  this  belief  he  removed  the  whole  mass,  when,  to  his  surprise, 
he  found  that  he  held  in  his  hands  the  inverted  uterus  with  its  tubes 
and  ligaments.  The  patient  recovered  without  any  bad  symptoms, 
and  subsequently  menstruated  regularly. 

Menstruation,  after  amputation  of  the  uterus,  is  by  no  means 
rare.  It  must  be  remembered  that  in  such  an  operation  the  whole 
uterus  is  not  removed.  It  is  from  the  remaining  stump  that  the 
flow  occurs. 

It  is  certainly  difficult  to  admit  the  occurrence  of  inversion 
beginning  in  the  body  of  an  undilated  uterus.  It  may  be  that  in 
these  cases  some  distending  influence  which  escaped  observation 
preceded  the  accident.  The  suggestion  of  Colombat  is  certainly 
very  plausible,  that  hydrometra,  physometra,  or  retention  of  the 
menses  must,  in  such  cases,  have  produced  dilatation,  which,  being 
followed  by  pressure  just  after  the  escape  of  the  contained  air  or 
fluid,  gave  rise  to  the  displacement.  It  may  be  that  inversion 
begins  in  such  cases  at  the  cervix  and  becomes  complete  in  the 
method  suggested  by  Taylor. 

After  all,  there  is  nothing  more  astounding  in  the  fact  of  spon- 
taneous inversion  of  an  undistended  uterus  than  there  is  in  the 
spontaneous  reposition  of  one  which  has  been  long  inverted,  and 
this  we  have,  with  the  positive  testimony  of  scientific  and  reliable 
men  now  on  record,  no  possible  justification  for  doubting.     Of  late 


'  Colombat  on  Femnles.     Meigs,  p.  182. 

^  Traite  des  Mai.  Chirurgicales.  ^  Colombat,  op.  cit. 


SYMPTOMS, 


429 


the  validity  of  both  these  phenomena  has  been  denied.  There  is 
nothing  easier  than  the  rejection  of  the  testimony  of  others,  and 
the  discrediting  of  deductions  which  we  ourselves  have  not  drawn. 
When  De  La  Barre  presented  his  case  of  spontaneous  reposition 
to  the  Academy  of  Surgery,  Baudelocque  was  appointed  a  com- 
mittee to  examine  into  it,  and  reported  that  it  was  "  totally  false." 
^ome  years  afterwards  he  met  with  a  very  similar  case,  and  yielded 
to  the  evidence  of  his  own  senses  a  credence  which  he  had  pre- 
sumptuously denied  to  the  assertions  of  another. 

Symptoms. — Should  inversion  occur  suddenly,  as  for  instance 
after  delivery,  the  patient  will  complain  of  discomfort  about  the 
vulva,  faintness  and  nervous  disturbance.  Hemorrhage  and  ten- 
dency to  collapse  will  show  themselves,  and  unless  proper  treat- 
ment be  adopted  at  an  early  period,  death  may  ensue.  A  physical 
examination  will  at  once  settle  the  diagnosis,  for  a  large,  flabby, 
globular  mass,  perhaps  with  the  placenta  attached  to  it,  will  be 
found  between  the  thighs  of  the  patient  if  inversion  be  complete. 
But  very  often  no  diagnosis  will  have  been  made  at  the  time  of 
its  occurrencte,  and  months,  perhaps  years,  afterwards,  the  physician 
will  be  called  upon  to  determine  the  character  of  the  case,  which 
will  probably  present  the  following  symptoms: 

Occasional  or  constant  hemorrhage; 

Dragging  pains  in  back  and  loins ; 

Difficulty  in  locomotion; 

Difficulty  in  defecation  and  micturition; 

Anaemia  and  its  accompanjdng  evils. 

Physical  Signs, — ^All  these  symptoms  belong  as  much  to  polypus, 
fibrous  tumor,  and  cancer,  as  to  inversion,  and  to  determine  their 
true  cause,  physical  exploration  is  indispensable.  Should  the 
inversion  be  complete,  the  finger  being  introduced  into  the  vagina 
will  meet  with  a  tumor  which  the  examiner  will  at  once  know  is 
either  the  displaced  body  of  the  uterus  or  a  polypus,  and  his  atten- 
tion will  be  directed  to  their  difterentiation. 


IF  IT  BE  A  POLYPUS. 

The  probe  will  usually  pass  by  its  side 
into  the  uterus; 

Conjoined  manipulation  will  reveal 
the  uterine  body  ; 

Rectal  examination  will  reveal  the 
uterus  in  situ  ; 

Recto-vesical  exploration  will  reveal 
the  uterus ; 

Acupuncture  will  give  no  pain.' 


IF  IT  BF  INVFRSTON. 

The  probe  will  be  arrested  at  the  neck  ; 

Conjoined  manipulation  will  reveal  a 
rinp:  where  the  uterus  should  be  ;  ' 

Rectal  examination  will  not  reveal  the 
uterus  in  sitd  ; 

Recto-vesical  exploration  will  not  re- 
veal the  uterus ; 

Acupuncture  will  give  pain. 


>  Gueniot,  Arch.  G6n.  de  Med.,  1868,  t.  ii.  p.  393. 


430 


INVERSION    OF    THE    UTERUS. 
Fig.  133.  Fig.  134. 


Polypus. 


Inversion. 


In  certain  very  rare  cases,  a  large  fibrous  tumor  growing  from 
one  lip  of  the  cervix,  will  lead  to  the  belief  in  inversion  in  the 
following  manner:  the  pedicle  setting  up  inflammation  in  the 
cervical  canal,  complete  adhesion  takes  place,  so  that  a  probe  can 
nowhere  be  passed.  An  examination  of  Fig.  133  will  readily 
explain  how  such  a  state  of  thing's  might  arise  and  prove  exceed- 
ingly perplexing.  I  have  seen  two  such  cases,  one  with  Dr.  Byrne 
of  Brooklyn,  and  another  with  Dr.  Ross  at  my  clinique,  in  both 
of  which  recognition  of  the  presence  of  the  uterine  body  above, 
emboldened  me  to  work  the  probe  through  the  tissue  around  the 
pedicle  of  the  growth,  causing  it  to  enter  the  uterus,  and  thus 
prove  incontestabl}^  the  nature  of  the  case. 

Should  the  inversion  be  incomplete,  diagnosis  will  always  prove 
diflicult,  and  in  fat  women  particularly  so.  Differentiation  from 
a  fibrous  tumor  will  depend  upon  the  following  signs: 


IF    IT  BK  A  FIBROID  GROWTH. 

The  probe  will  show  increase  of  uterine 
cavity ; 

Conjoined  manipulation  and  Simon's 
method  will  reveal  rotund  body  of  uterus  ; 

It  will  have  come  on  very  gradually ; 

It  will  have  no  reference  to  parturition  ; 

Acupuncture  is  painless. 


IF  IT  BE  PARTIAL  INVERSION. 

The  probe  will  show  diminution  of 
uterine  cavity ; 

Conjoined  manipulation  and  Simon's 
method  will  reveal  small  abdominal  ring  ; 

It  will  have  occurred  more  suddenly ; 

It  usually  follows  parturition  ; 

Acupuncture  gives  paia. 


PROGNOSIS.  431 

Fiff.  135.  Fig.  136. 


Fibrous  polypus.  Partial  inversion. 

Course^  Duration^  and  Termination. — All  these  are  very  variable. 
The  accident  occurring  after  delivery  may  rapidly,  unless  relieved, 
produce  death  by  hemorrhage  and  exhaustion ;  or  it  may  continue 
for  many  years,  giving  very  little  annoyance ;  or,  again,  it  may 
render  the  life  of  the  patient  miserable  on  account  of  hemorrhage 
and  •  other  attending  symptoms,  and  nevertheless  last  for  years. 
As  a  rule,  it  may  be  stated  that  inversion  continues  until  relieved 
by  treatment,  and  yet  even  this  is  not  without  exceptions.  The 
womb  has  been  known  under  these  circumstances  to  replace  itself 
by  its  own  contractions,  years  after  its  occurrence,  when  the  acci- 
dent has  happened  after  delivery.  Twelve  such  cases  have  now 
been  placed  upon  record :  three  by  Meigs,^  and  one  by  each  of  the 
following  observers:  Spiegelberg,^  Leroux,^  De  la  Barre,^  Thatcher,^ 
Eendu,^  Shaw,^  Beaudeloeque,*  Foujen,*  and  Huckins.^  Even  ad- 
mitting the  undoubted  authenticity  of  these  cases,  spontaneous 
reduction  must  be  regarded  only  as  a  curiosity,  and  not  as  a  process 
to  be  anticipated. 

Prognosis. — The  prognosis  of  chronic  inversion  is  at  all  times 
grave.  Repeated  and  prolonged  hemorrhages  prostrate  the  patient, 
and  expose  her  to  all  the  risks  of  the  worst  forms  of  uterine 
polypi.  But  not  only  is  she  exposed  to  dangers  inherent  to  the 
displacement  from  which  she  suffers;  those  attendant  upon  an 
erroneous  diagnosis  are  very  great.     To  one  alive  to  the  possibility 

'  Obstetrics. 

2  Article  by  Prof.  Spiegelberg,  '•  Archiv  fur  Gynakologie,"  Am.  Jonrn.  Obstet., 
Aug.  1873. 

3  Daillez,  Thesis.  •*  Weiss,  Des  R6dnctions  de  I'luversiou,  etc. 
^  Letter  to  author  from  Dr.  Jason  Huckins,  of  Maiue,  U.  S. 


432  INVERSION    OF    THE    UTERUS. 

of  confounding  the  condition  with  fibrous  polypus,  the  methods 
of  differentiation  are  numerous  and  reliable;  but  to  the  rapid 
and  careless  diagnostician,  who  does  not  allow  the  possibility  of 
error  to  enter  his  mind,  and  consequently  does  not  carefully  weigh 
the  evidence,  there  is  a  great  likelihood  of  it. 

One  who  is  aware  of  the  great  frequency  with  Avhich  amputation 
of  the  inverted  uterus  has  been  practised,  under  the  impression 
that  a  fibrous  polypus  was  being  removed,  cannot  but  wonder  that 
errors  of  diagnosis  have  so  often  occurred,  when  so  many  methods 
of  differentiation  were  at  command.  The  explanation  is  that  to 
which  I  have  referred,  namely,  that  the  possibility  of  error  was 
not  entertained.  Out  of  fifty -eight  cases  of  inversion  of  which  a 
report  is  given  in  the  "  Beitroege  zur  Geburtskunde  und  Gyna- 
kologie,"  and  in  which  amputation  was  practised,  seven  were  mis- 
taken for  polypi. 

Even  where  a  correct  diagnosis  has  been  made,  still  another  dan- 
ger menaces  the  patient;  that  of  rupture  of  the  vagina  in  attempts 
at  reduction  of  the  inverted  organ.  A  small  hand,  a  cautious, 
unexcitable  mind,  and  constant  vigilance  during  all  the  efforts  by 
taxis,  must  be  combined  with  thorough  knowledge  of  the  subject, 
to  avoid  this  imminent  danger.  Even  with  all  this  combination, 
it  is  a  matter  of  surprise  to  me,  from  my  experience  with  these 
cases,  that  the  accident  has  not  occurred  much  oftener.  I  con- 
fess that  I  should  prefer  to  trust  a  patient  in  whom  I  felt  great 
interest  to  the  operation  of  abdominal  section,  which  is  hereafter 
described,  than  to  that  of  prolonged  taxis  at  the  hands  of  a  rough, 
unintelligent,  and  inexperienced  practitioner.  To  one  thinking 
upon  this  subject  for  the  first  time,  this  position  will  appear  exag- 
gerated and  indefensible ;  but  I  assume  it  after  mature  reflection. 

When  the  prospect  of  returning  the  uterus  seems  brightest,  the 
practitioner  is  sometimes  disappointed  by  the  existence  of  adhesions. 
Thus  Velpeau,'  after  the  removal  of  a  polypus  attached  to  an  in- 
verted uterus,  was  completely  foiled  in  restoring  it,  and  the  patient 
died  from  peritonitis. 

Treatment. — In  the  treatment  of  inversion,  three  methods  may 
be  adopted. 

1st.  The  organ  may  be  left  in  malposition;  hemorrhage  being 
controlled  by  hemostatic  means. 

2d.  The  inversion  may  be  reduced  by  taxis,  by  elastic  vaginal 
pressure,  or  by  a  combination  of  the  two. 

'  Becquerel,  op,  cit.,  p.  306. 


TREATMENT.  433 

3d.  All  these  failing  to  give  relief,  the  uterus  may  be  amputated. 

Methods  of  Checking  Hemorrhage^  the  Uterus  being  left  in  situ. — 
Should  the  operator  fail  in  repeated  attempts  at  reduction,  it  be- 
comes a  question  whether  he  should  amputate  the  displaced  organ 
or  leave  it  in  its  abnormal  position  and  endeavor  to  combat  the 
evils  resulting.  The  greatest  of  these  is  unquestionably  hemor- 
rhage, which  steadily  exhausts  the  patient;  but  others  of  less 
moment  arise  from  dragging  of  the  uterus  upon  its  ligaments  and 
the  mechanical  inconvenience  of  a  tumor  in  the  vagina.  If  the 
patient  be  near  the  menopause,  both  of  these  may  diminish  b}" 
atrophy  and  cessation  of  menstruation.  Should  she  be  young, 
artiiicial  means  may,  in  a  limited  degree,  accomplish  the  same 
results. 

The  most  vascular  growths,  such,  for  example,  as  hemorrhoids 
and  naevi,  may  be  diminished  in  size  and  rendered  non-hemor- 
rhagic  by  astringents  or  caustics,  which  destroy  their  superficial 
varicose  vessels  and  leave  a  less  vascular  tissue  beneath.  The  in- 
verted uterus  may  be  similarly  acted  upon,  not  only  in  checking 
hemorrhage,  but  in  producing  atrophy,  and  thus  removing,  to  a 
certain  extent,  the  two  sources  of  suifering. 

Solutions  of  alum,  tannin,  persulphate  of  iron,  or  acetate  of 
lead  may  with  advantage  be  injected  into  the  vagina  so  as  to  bathe 
the  uterus  freely,  or  they  may  be  placed  in  contact  with  it  by 
means  of  pledgets  of  cotton.  Should  these  fail  in  checking  the 
flow,  a  plan,  proposed  by  Aran,  of  applying  caustics  to  the  whole 
bleeding'  surface,  may  be  resorted  to.  The  tumor  being  dra-wii 
down  and  exposed  to  view  as  much  as  possible,  its  surface  is 
seared  by  the  actual  cautery  or  touched  by  potassa  cum  calce  or 
the  mineral  acids.  The  organ,  after  being  bathed  in  a  neutralizing 
fluid,  is  then  enveloped  in  lint,  so  as  to  protect  the  vaginal  walls, 
and  placed  within  the  pelvis.  I  have  never  seen  the  method 
employed,  but  would  not  hesitate  in  an  appropriate  case  to  venture 
upon  it.  Aran  declares  that  not  only  is  hemorrhage  checked;  by 
it,  but  great  diminution  of  the  tumor  eflfected.  The  procedure 
recommends  itself  as  eminently  rational,  and  when  it  is  remeni- 
bered  that  the  only  recognized  alternative  is  amputation,  the  pro- 
priety of  giving  it  consideration  must  be  admitted. 

Many  cases  are  on  record  in  which  the  uterine  mucous  mem- 
brane has  become  altered  so  as  to  resemble  skin,  and  in  which  the 
patients  have  lived  without  suffering  for  many  years.  Dr.  Alex- 
ander II.  Stevens  had  one  case  under  observation  for  more  thaii 
thirty  years  •  Dr.  Charles  A.  Lee  diagnosticated  one  whioL  had 
28 


434  INVERSION"    OF    THE    UTERUS. 

remained  uncletectecl  for  twenty-five  years  ;  and  the  works  of  older 
writers  oiFer  many  other  examples.  If  we  can  bring  about  a  simi- 
lar condition  by  artificial  means  and  avoid  the  operation  of  abla- 
tion, we  will  certainly  be  acting  in  the  best  interests  of  the  patient. 
It  is  for  this  purpose  that  cauterization  offers  itself  as  a  resource. 

Methods  of  Replacing  the  Uterus. — It  is  not  certainly  known 
whether  the  condition  of  inversion  of  the  uterus  was  properly  un- 
derstood before  the  time  of  Ambrose  Pare.  Since  his  epoch  it  has 
been  fully  described  by  his  successors,  and  all  its  pathological  fea- 
tures, its  various  symptoms,  and  its  manifold  dangers,  have  been 
thoroughly  apjjreciated.  From  the  time  of  Pare,  who  lived  about 
the  middle  of  the  seventeenth  century,  to  our  own,  although  great 
advances  were  made  in  the  scientific  department  of  the  subject, 
very  little  was  attained  in  the  way  of  treatment.  The  possibility 
of  replacing  by  taxis  a  uterus  recently  inverted  was  known,  but 
for  cases  in  which  the  organ  had  been  displaced  for  years,  or  even 
for  months,  no  resource  existed  except  amputation. 

It  is  certainly  one  of  the  many  triumphs  of  which  the  gynecology 
of  the  nineteenth  century  can  boast,  that  this  accident  has  been 
proved  to  be  amenable  to  conservative  measures,  and  that  taxis  has 
been  shown  to  be  capable  of  effecting  a  cure,  and  preventing  a  re- 
sort to  a  mutilating  surgical  procedure. 

So  far  as  I  have  been  able  to  ascertain,  the  first  cases  of  chronic 
inversion  which  were  successfully  reduced  by  taxis  are  those  men- 
tioned by  Colombat^  in  the  following  passage:  "Dr.  Daillez^  re- 
ports in  his  dissertation  that  the  surgeon,  Labarre  De  Benzeville, 
had  effected  the  reduction  as  late  as  the  eighth  month,  and  Bau- 
delocque  after  eight  years."  In  later  times  the  first  successful  case 
occurred  in  1847.^  The  inversion  had  lasted  more  than  a  3^ear, 
when  M.  Valentin,  by  introducing  one  hand  into  the  vagina,  and 
making  counter-pressure  by  the  other  over  the  abdomen,  succeeded 
in  reducing  the  displaced  fundus  in  ten  minutes.  In  1852,  Mr. 
Canney^  in  the  same  manner  efifected  reduction  in  a  case  of  five 
months'  standing,  and  in  the  same  year  M.  Barrier*  accomplished 
it  in  one  which  had  existed  for  fifteen  months. 

Up  to  the  year  1858,  the  reposition  of  inverted  uteri  may  be  said 
to  have  been  limited  to  replacement,  within  short  periods  after 
parturition.    It  is  true  that  occasional  cases  had  occurred  in  which 

'  Colombat,  Am.  ed.,  p.  186. 

2  Paillez's  Thesis  appeared  in  1803. 

3  Quoted  from  Ranking's  Abstract,  vol.  7,  by  G.  Hewitt. 
*  Courty,  Mai.  de  I'Uterus,  p.  797. 


METHODS  OF  EEPLACING  THE  UTERUS.        435 

chronic  inversion  had  been  overcome  by  taxis  and  pressure,  but 
these  held  the  position  of  accidental  and  anomalous  feats  in  treat- 
ment, not  that  of  systematic  procedures,  which  it  was  incumbent 
upon  the  practitioner  to  essay  in  every  case.  At  this  period  two 
cases  of  chronic  inversion  were  reduced,  one  of  twelve  years'  stand- 
ing by  Prof.  Tyler  Smith,  of  London,  by  elastic  pressure  and  taxis; 
the  other  of  almost  six  months'  standing  by  Prof.  James  P.  White, 
of  Buifalo,  U.  S.,  by  taxis  alone.  Each^  of  these  gentlemen  worked 
without  the  knowledge  of  what  the  other  was  doing  ;  and  to  them 
belongs  the  great  credit  of  having  systematized,  and  made  subser- 
vient to  science  and  humanity,  a  method  which  before  had  been 
"practised  in  a  loose  and  desultory  manner.  Soon  after  their  publi- 
cations, cases  of  cure  effected  by  taxis  alone,  or  combined  with 
pressure  by  bags  of  air  or  water  jdaced  in  the  vagina,  were  rapidly 
reported  from  different  parts  of  the  world.  Most  notable  among 
these  were  the  cases  of  Noeggerath,  of  13  years'  standing ;  Teale, 
of  2|-  years;  West,  of  1  3'ear ;  White,  of  15  years;  and  Bocken- 
dalil,  of  6  years.  When  it  is  stated  that  all  these  occurred  in  1859, 
it  will  be  fully  appreciated  how  great  an  impetus  was  given  to  this 
subject  by  the  successes  of  Smith  and  White.  Within  the  past  ten 
years  cures  have  multiplied  so  rapidly  as  to  preclude  the  mention 
of  individual  cases  in  a  work  of  the  character  of  this ;  and,  although 
I  cannot  go  so  far  as  to  endorse  the  sanguine  prediction  of  White, 
made  in  1872,  that  "  well  directed  pressure  upon  the  fundus,  if 
continued  long  enough,  will,  in  all  cases  where  there  are  no  adhe- 
sions, result  in  restoration  or  reposition,"  I  do  believe  that  the  day 
has  passed  when  any  practitioner  would  be  held  blameless  by  a 
jury  of  his  peers,  who  has  either  left  untouched,  or  amputated  a 
uterus  in  the  condition  of  chronic  inversion,  without  some  special 
reason  apart  from  the  mere  displacement  itself. 

The  best  methods  at  our  command  for  replacing  an  inverted 
uterus  may  thus  be  presented : 

'  I  feel  that  full  justice  was  inadvertently  withheld  from  Dr.  White  in  the  former 
editions  of  this  work.  My  space  does  not  allow  me  to  state  the  grounds  upon  which 
I  place  him  on  an  equality  with  Dr.  Smith,  in  reference  to  this  matter ;  but  any  one 
desiring  details  will  find  them  in  an  article  by  Dr.  White  in  the  "  Richmond  and 
Louisville  Journal"  for  August,  1872. 


436  INVERSION    OF    THE    UTEEUS. 

f  Pressure  by  vaginal  stem  and  cup  or  bulb ; 
Methods  for  effecting  I   Elastic  pressure  combined  with  taxis; 
gradual  reduction     '  Elastic  pressure  alone ; 
A  stream  of  cold  water. 


Methods  for  effecting 
rapid  reduction 


Manipulation  by  Viardel's   method; 
"  "    A^hite's  " 

"  "    Barrier's         " 

"  "    Noeggerath's  " 

"  "    Courty's  " 

"  "    Thomas's        " 


I^one  of  these  methods  are  free  from  danger ;  in  several  cases 
even  elastic  pressure  has  excited  fatal  peritonitis.  But  gradual 
reposition  is  certainly  much  safer  than  rapid  reduction. 

Before  each  of  these  certain  preparatory  measures  calculated  to 
relax  the  cervical  parenchyma,  or  render  its  resistance  less  decided, 
may  be  essayed.  One  of  these  is  the  use  of  belladonna  by  the 
vagina  in  the  form  of  vaginal  injections  of  the  infusion,  or  of 
ointment  smeared  around  the  uterine  neck ;  or  by  the  rectum  in 
form  of  suppository.  The  other  is  the  making  of  two  or  three 
longitudinal  incisions  through  the  superficial  layers  of  the  paren- 
chyma of  tbe  neck.  This  method  is  a  very  old  one,  dating  back  to 
Millot^  in  1773.  Since  his  time  it  has  been  repeatedly  advised; 
for  example,  by  Colombat,  Gross,  Sims,  Barnes,  and  others.  Of 
the  benefit  of  the  first  of  these  methods  there  is  little  doubt ;  of 
that  of  the  second  there  is  none. 

Gradual  Reduction  hy  Hcpositor. — This  method  dates  back  to  Yon 
Siebold,^  who  employed  a  curved  stem  surmounted  by  a  fine  sponge, 
the  stem  being  held  in  situ  by  a  T  bandage.  After  him  it  was 
repeatedly  and  successfully  employed,  and  to-day  it  is  coming  again 
into  favor,  having  been  very  recently  recommended  by  Drs.  Ilicks 
and  Barnes  of  London.  The  former  employs  a  solid  stethoscope, 
the  large  extremity  covered  by  India-rubl)er ;  the  latter  a  hollow 
caoutchouc  cup,  fixed  to  a  curved  stem.  Both  of  these  are  sup- 
ported by  a  T  bandage. 

£i/  Elastic  Pressure. — The  demonstration  of  the  important  fact, 
the  most  important,  indeed,  connected  with  this  subject,  that  ela  ,tic 
pressure  was  capable  of  greatly  aiding  reposition  of  an  inverted 
uterus,  belongs  to  the  late  Dr.  Tyler  Smith.  I  say  "  greatly  aiding," 
for  he  combined  taxis  with  it.     It  was  left  for  Bockendahl,  of 


'  Taylor,  op.  cit.  2  (^\^  p  Weiss,  Paris,  op.  cit. 


METHODS  OF  REPLACING  THE  UTERUS.        437 

Germany,  to  prove  that  it  could  eltect  reduction  unaided.  Smith's 
plan  consists  in  passing  the  hand  into  the  vagina,  night  and  morn- 
ing, and  kneading  the  uterus  for  ten  minutes,  and  during  all  the 
intervening  period  keeping  an  air  pessary  in  the  vagina.  Bock- 
endahl  simply  trusts  to  elastic  pressure  alone,  thus  making  an 
important  improvement  upon  Smith's  plan. 

A  Stream  of  Cold  Water. — This  method  has  not  been  sufficiently 
tested  to  command  confidence,  but  it  is  worthy  of  mention  and 
consideration.  Dr.  Charles  Martin,^  of  France,  succeeded  in  effect- 
ing reduction  in  a  case  which  proved  rebellious  to  other  means  by 
this,  which  he  tried  in  the  following  manner:  he  introduced  the 
speculum  around  the  inverted  uterus  twice  a  day  and  threw  upon 
the  fundus,  with  force,  by  means  of  a  syringe,  a  stream  of  cold 
water.  Then  filling  the  speculum  with  cold  water,  he  kept  the 
uterus  immersed  for  three  or  four  minutes.  My  impression  is  that, 
simple  as  this  method  is,  we  shall  hear  of  it  again. 

There  is  no  limit  to  the  time  during  which  efforts  at  gradual 
reduction  may  be  persevered  in.  Such  a  limit  is  established  solely 
by  the  patient's  tolerance  of  the  method  tried.  A  case  is  mentioned 
in  this  chapter  in  which  elastic  pressure  was  kept  up  for  eighteen 
days  with  successful  result.  Sometimes,  however,  the  patient  can- 
not tolerate  elastic  pressure,  or  that  by  a  repositor,  for  symptoms  of 
peritonitis  result  from  their  use.  Then  it  is  that  anaesthesia  and 
rapid  reduction  offer  themselves  as  valuable  resources. 

Mapid  Reduction  by  the  Old  Methods  of  Taxis. — Taxis  has  been 
practised  for  the  reduction  of  chronic  inversion  certainly  since  the 
beginning  of  this  century,  and  perhaps  before  that  time,  in  two 
entirely  distinct  methods.  First,  the  manipulations  of  the  operator 
are  directed  to  the  constricting  cervix,  in  order  to  overcome  resist- 
ance there,  and  to  return  first  the  parts  which  last  escaped.  Second, 
these  manipulations  are  directed  to  the  body,  in  order  to  return 
first  the  parts  which  escaped  first.  The  first  of  these  methods  is 
thus  described  by  Capuron:^  "If  the  orifice  be  not  sufficiently 
dilated  to  allow  the  inverted  portion  to  return  easily,  it  is  a  better 
plan  to  take  the  tumor  in  the  palm  of  the  hand,  with  the  fingers 
distributed  around  its  pedicle,  and  to  reduce  first  the  portion  which 
was  inverted  last,  as  if  we  were  dealing  with  a  hernia."  "We 
encounter  at  this  point,"  says  Aran,-''  "  two  opinions  which  have 
arisen  in  relation  to  the  reduction  of  the  uterus  inverted  during 


'  Gaz.  des  Hop.,  1853.  ^  Tyjal.  des  Femmes,  2d  ed.,  p.  510. 

3  Mai.  de  I'Uterus,  p.  901. 


438  INVERSION    OF    THE    UTERUS. 

labor;  one  party  desiring  to  return  first  the  parts  which  escaped 
last,  subjecting  the  uterus  to  a  general  compression,  so  as  to  soften 
it  to  a  certain  extent  and  force  it  to  pass  the  orifice  little  by  little, 

commencing  with  the  least  voluminous  parts Arrived 

at  the  tumor,  if  the  operator  wishes  to  employ  the  first  method,  he 
kneads  it  so  as  to  soften  it,  and  cause  it  to  pass  more  easily  through 
the  constricted  orifice  in  which  he  engages  his  fingers."  BecquereP 
describes  it  thus:  "It  is  advisable,  as  far  as  practicable,  to  return 
first  the  i)arts  which  last  escaped ;  for  in  this  way  we  dilate  in 
advance  the  muscular  fibres  which  oppose  reduction.  (P.  Duljois 
Danyau.)    .     .     .     .     M.  Vel})eau  considers  this  the  best  method." 

The  second  method  of  taxis  consists,  not  in  manipulating  the 
"  constricted  orifice  in  which  he  engages  his  fingers,"  so  as  to 
"  dilate  in  advance  the  muscular  fibres  which  oppose  reduction," 
as  Aran  and  Becquerel  express  it;  but  in  dimpling  or  indenting 
the  fundus  itself,  so  as  to  make  of  the  indented  or  invaginated  por- 
tion a  species  of  wedge,  which  is  forced  into  the  cervical  constric- 
tion. In  recent  cases  of  inversion,  occurring,  as  the  vast  majority 
of  these  cases  do,  after  labor,  350  out  of  400  reported  by  Crosse 
having  done  so,  the  centre  of  the  fundus  may  be  indented  and 
carried  up  through  the  cervical  canal ;  and  even  in  chronic  cases 
such  an  invagination  has  been  attempted.  My  impression  is  that 
the  manipulations  practised  on  the  fundus  in  chronic  cases  act  not 
in  this  way,  but  in  overcoming  cervical  resistance,  and  thus  accom- 
plishing in  a  more  indirect  and  imperfect  way  what  the  French 
method,  styled  the  method  of  Viardel  by  Becquerel,  does  by  en- 
gagement of  the  fingers  within,  and  direct  expansion  of,  the  cer- 
vical constriction.  It  is  scarcely  applicable  to  other  than  recent 
cases. 

The  diagnosis  having  been  clearly  made  and  reduction  deter- 
mined upon,  the  bowels  and  bladder  should  be  emptied,  and  the 
patient  put  under  the  influence  of  an  anesthetic,  and  laid  on  licr 
back  upon  a  strong  table.  The  operator  should  always  be  attended 
by  three  or  four  reliable  counsellors,  upon  whom  he  may  call  not 
only  for  advice  but  physical  aid.  As  the  late  Prof.  Elliot  h:is 
pointed  out,  the  strength  of  one  man  will  often  fail  to  accomplish 
what  that  of  several,  replacing  each  other  in  rapid  succession,  will 
readily  effect.  Having  thoroughly  oiled  one  hand,  the  nails  of 
which  have  been  pared,  the  operator  should  slowly  dilate  the 
vagina  so  as  to  introduce  it,  and  grasp  in  its  palm  the  entire  tumor. 

'  Mai.  (It"  rUt^rns.  tome  2,  p.  314. 


METHODS  OF  REPLACING  THE  UTERUS. 


439 


The  other  hand  should  he  laid  upon  the  ahdomen  so  as  to  press  just 
over  the  ring  which  marks  the  non-inverted  cervix,  and  oppose  the 
force  exerted  through  the  vagina,  so  as  to  prevent  too  great  stretch- 
ing of  this  canal. 

In  a  case  of  four  years'  standing,  which  I  attended  with  Dr. 
Joseph  Worster,  of  this  city,  and  which  had  been  subjected  to 
eight  attempts  previous  to  my  seeing  it,  each  varying  in  duration 
from  two  to  three  hours,  I  suggested  substituting  for  the  hand  a 
cone  of  boxwood  four  inches  long.  The  patient  being  very  thin, 
this  could  readily  be  inserted  into  the  abdominal  ring  of  the  uterus, 
and  it  was  gradually  forced  down  into  the  inverted  fundus  for  such 
a  distance  as  to  dilate  the  cervix  and  allow  reposition. 

The  use  of  a  repositor  by  which  to  make  direct  pressure  and  aid 
in  reduction  has  been  resorted  to  by  Depaul  and  others.  Prof. 
J.  P.  White  has  recently  employed  one  which  by  its  simplicity  and 
efficacy  makes  it  worthy  of  especial  mention.     Fig.  137  shows  this 


Rapid  reduction  by  White's  method.    Operator  grasps  uterus,  a,  and  presses  his  chest 
against  spiral  spring,  g,f,  which  forces  cup  of  repositor  against  fundus. 


instrument,  and,  likewise,  makes  evident  the  method  of  reduction 
which  the  experience  of  nine  cases  extending  over  a  period  of  fifteen 
years  has  led  him  to  adopt. 

It  is  impossible  to  set  an  absolute  limit  to  the  time  which  should 
be  allotted  to  one  attempt  at  immediate  reduction,  but  these  efforts 


440  INVERSION    OF    THE    UTERUS. 

cannot  be  persisted  in  much  longer  than  one  or  two  hours  without 
great  danger  of  cellulitis  or  peritonitis.  It  is  true  that  numbers 
of  successful  cases  are  on  record  in  which  from  three  to  five  hours 
have  been  spent  in  continuous  exertion  before  success  was  accom- 
plished, and  in  which  no  unfavorable  symptoms  have  arisen;  but  a 
safer  and  more  j  udicious  course  would  be  to  desist  after  a  reason- 
able effort,  secure  what  has  been  gained  by  placing  a  caoutchouc 
bag  in  the  vagina,  or  closing  the  os  uteri  by  silver  sutures  as 
practised  by  Emmet,  administer  a  large  dose  of  opium,  and  make 
another  attempt  in  thirty-six  or  forty-eight  hours.  Manipulation 
should  then  be  cautiously  rej^eated  for  about  the  same  period,  and 
again,  in  case  of  failure,  followed  by  the  air  bag,  or  closure  by 
suture. 

The  operator  should  not  adhere  too  long  to  one  plan  of  manipu- 
lation, but  try  one  after  the  other  of  the  other  methods  of  manipu- 
lation which  will  now  be  mentioned. 

Barrier^s  Method  consists  in  spreading  the  four  fingers  around 
the  uterus,  pressing  the  thumb  against  the  fundus,  and  forcing  tlu' 
neck  against  the  curve  of  the  sacrum  as  a  point  of  resistance. 

NoeggeratJi's  3Iethod  consists  in  placing  the  index  finger  upon  one 
horn  of  the  uterus,  the  thumb  upon  the  other,  and  so  compressing 
as  to  invert  one  or  both  cornua.  Before  reinversion  of  the  neck  it 
should  not  be  tried.  For  reducing  the  body  after  the  neck  has 
yielded  it  is  a  most  valuable  plan.  I  have  succeeded  by  it  in  three 
out  of  five  cases  which  I  have  treated. 

Courty's  Method  consists  in  passing  the  index  and  middle  finger 
up  the  rectum,  dipping  them  into  the  cervical  ring,  and  thus  gaining 
a  point  of  resistance.  It  is  one  of  the  best  at  our  conmiand,  and 
may  be  combined  with  !N'oeggerath's  method,  one  being  directed 
to  reduction  of  the  neck,  the  other  to  that  of  the  body. 

Thomas's  Method.  Abdominal  Section  as  a  Substitute  for  Amputa- 
tion.— In  November,  1869,  I  ])ublished  an  account  of  a  case  success- 
fully treated  after  all  other  means,  except  am]>utation,  had  been 
resorted  to,  by  abdominal  section  and  intra-abdominal  dilatation 
of  the  cervical  ring.  I  trust  that  its  transference  from  the  Journal' 
in  which  it  appeared  to  these  pages  may  not  prove  tedious  or  un- 
profitable to  my  readers. 

Case  1.  On  the  10th  of  June,  1869,  I  received  a  letter  from  Mr. 
B.,  of  Louisville,  Kentucky,  detailing  the  following  facts : 

He  stated  that  his  wife,  aged  twenty-three  years,  a  native  of 

•  Amer.  Journ.  Obstetrics  and  Dis.  of  Women  and  Children. 


METHODS    OF    EEPLACING    THE    UTERUS.  441 

Indiana,  bad  enjoyed  good  health  until  twenty-one  months  before 
that  date.  At  that  time  she  bore  a  child,  and  since  then  she  had 
been  an  invalid. 

Menorrhagia  of  most  profuse  character  had  occurred  at  each 
menstrual  period,  and  for  its  relief  she  had  sought  medical  aid. 
The  physician  who  was  consulted  prescribed  astringents  and 
hemostatics,  but  did  not  explore  the  vagina  for  the  cause  of  the 
difficulty.  Eight  months  after  her  labor,  she  fortunately  applied 
to  Prof.  Henry  Miller,  of  Louisville,  the  accomplished  author  of 
"Miller's  Principles  and  Practice  of  Obstetrics."  This  gentleman 
at  once  recognized  the  nature  of  the  difficulty,  and  proceeded  to 
apply  the  proper  remedy.  On  five  occasions  he  anaesthetized  the 
patient  with  chloroform,  and  employed  taxis  for  an  hour  and  a  half. 
Each  effort  thus  made  was  followed  by  the  systematic  employment 
of  pressure  by  means  of  the  vaginal  air  pessary.  All  his  efforts 
were  of  no  avail.  The  patient  became  exhausted  and  discouraged, 
and  leaving  Louisville,  sought  the  aid  of  Prof.  Theophilus  Parvin, 
of  Indianapolis. 

Prof.  Parvin  made  five  determined  and  prolonged  attempts,  each 
one  lasting  from  four  to  six  hours,  the  patient  during  their  con- 
tinuance being  under  the  influence  of  ether,  and  each  being  syste- 
matically followed  by  the  air  pessary.  All  these  efiforts  resulted  in 
failure,  and  the  patient,  exhausted  and  almost  desperate,  returned 
to  her  home  in  Kentucky.  Here  she  met  with  Dr.  W.  M,  Allen, 
who  advised  her  to  make  still  another  trial,  and,  in  accordance 
with  his  counsel,  she  came  to  me  about  the  last  of  August. 

Upon  Mrs.  B.'s  arrival  in  this  city  I  was  away,  but  saw  her  on 
the  1st  of  September.  When  Mr.  B.  had  written  to  me,  asking 
for  a  frank  statement  as  to  what  hope  I  could  hold  out,  my  replv 
was,  that  after  Profs.  Miller  and  Parvin  had  failed,  I  was  inclined 
to  promise  nothing.  My  mind,  however,  was  so  possessed  by  the 
idea  that  belladonna,  the  warm  douche,  and  the  abdominal  plug, 
by  which  I  had  twice  succeeded,  once  in  a  rebellious  case,  and  once 
very  rapidly  in  a  simple  one,  would  succeed  in  this,  that  I  urged 
him  at  least  to  let  me  make  an  efiibrt. 

I  found  Mrs.  B.  to  be  a  delicate,  fragile  blonde,  weighing  about 
ninety  pounds,  very  pale  and  exsanguinated  from  profuse  menor- 
rhagia,  which  had  occurred  at  intervals  for  twenty-one  months, 
and  much  disheartened  by  the  failure  of  her  eminent  medical 
advisers. 

The  patient  was  rapidly  brought  under  the  full  influence  of 
belladonna,  administered   l)y   rectal   suppository,  and    the   warm 


442  INVEESION    OF    THE    UTERUS. 

douclie  was  employed  three  times  daily,  for  an  hour  each  time.  At 
the  end  of  a  week  she  was  anaesthetized  with  ether,  placed  upon 
the  back  upon  a  table,  and  aided  by  Drs.  Nott,  Metcalfe,  and  "Walker, 
I  proceeded  to  make  my  lirst  attempt  at  reduction  by  taxis.  For 
one  hour  I  tried  faithfully  all  the  varieties  of  taxis  to  which  allu- 
sion has  been  made,  and  made  counter-pressure  by  the  abdominal 
plug,  but  all  to  no  purpose.  The  cervix  expanded  nearly  up  to  the 
OS  internum,  but  no  further  would  it  yield. 

Filling  the  vagina  with  a  caoutchouc  bag,  and  distending  this 
with  very  warm  water,  she  was  now  put  into  bed.  On  the  next 
day  at  the  same  hour,  exactly  the  same  procedure  was  gone  through 
with.  The  result  was  the  same,  and  at  the  conclusion  of  the  attempt 
the  bag  was  replaced,  filled  with  warm  water,  and  on  the  next  day 
the  third  trial  was  made. 

At  the  end  of  the  hour  no  advance  was  obtained,  and  I  now 
began  to  share  the  opinion  of  Dr.  Miller,  that  adhesions  existed 
within  the  sac,  and  that  no  amount  of  taxis  would  ever  reduce  the 
displaced  fundus. 

For  cases  in  which  reduction  has  been  so  far  eiFected  that  the 
fundus  can  be  pushed  up  to  a  level  with  the  external  os.  Dr.  Emmet 
has  advised  and  practised  a  method  which  appears  to  me  to  be 
most  excellent.  It  consists  in  closure  of  the  os  externum  by  silver 
sutures,  so  that  the  fundus,  imprisoned  in  the  cavity  of  the  neck, 
tends  to  dilate  the  constriction  near  tlie  os  internum.  At  a  sub- 
sequent period  the  stitches  are  removed  and  taxis  is  practised  again. 
I  should  have  resorted  to  this  plan  here,  but  the  fundus  was  never 
suiRciently  high  to  admit  of  its  retention  in  this  way.  Dr.  Emmet's 
method  will  be  found  described  at  length  in  the  "  Amer.  Jourii.  of 
the  Med.  Sciences"  for  January,  1868. 

On  the  next  day  we  met  again,  in  the  case  of  Mrs.  B.  Being 
desirous  of  giving  the  patient  the  advantage  of  every  resource 
which  would  save  her  from  a  dangerous  capital  operation,  I  went 
to  the  consultation  prepared  to  offer  two  suggestions:  the  first  was 
that  I  should  pass  a  delicate  tenotome  through  the  fundus,  carry 
it  up  through  the  cervical  canal,  and  incise  its  four  sides  so  as  to 
cut  through  the  constriction  existing  there,  and  due  to  the  fibres 
near  the  os  internum;  the  second  was,  that  I  should  draw  the 
uterus  outside  the  body  and  cut  downward  through  the  mucous 
membrane.  The  patient  having  been  anresthetized,  I  manipulated 
as  usual,  except  that  I  employed  greater  force,  for  twenty  minutes, 
At  the  end  of  this  time,  no  progress  being  observed,  we  consulted 
upon  my  propositions,  and,  with  the  acquiescence  of  my  colleagues, 


METHODS    OF    REPLACING    THE    UTERUS.  443 

I  j)ushed  the  uterus  up  as  far  as  it  would  go,  then,  fixing  by  my 
finger  the  point  of  constriction,  I  drew  it  down,  and  cut  down 
through  the  tissue  of  the  neck,  the  incision  first  involving  the 
mucous  membrane  and  extending  down  toward  the  subjacent 
peritoneum,  as  recommended  by  Aran.^ 

'No  sooner  was  the  knife  withdrawn  than  a  free  jet  of  blood  was 
projected  from  an  artery  which  appeared  nearly  equal  in  size  to 
the  radial.  This  jet  was  not  per  saltum,  but  steady,  as  it  is  often 
seen  to  be  from  small  arteries  located  in  dense  fibrous  tissue.  I 
presume  that  I  cut  the  circular  artery  of  the  neck,  which  had 
become  increased  in  size  by  the  displacement  of  the  uterus.  For 
a  half  hour  we  strove  to  ligate  this.  Upwards  of  a  dozen  ligatures 
were  one  after  another  applied,  but  the  vessel  had  retracted  into 
the  brittle  tissue  of  the  uterus,  and  could  not  be  tied.  Dr.  AV"alker 
went  for  the  actual  cautery,  but  before  his  return  the  flow  was 
checked  by  Dr.  Soft's  passing  a  suture  through  both  lips  of  the 
wound,  and  bringing  them  forcibly  together.  Of  course  all  efforts 
at  taxis  were  at  an  end  for  the  present ;  nor  did  I  think  it  wise  or 
warrantable  again  to  renew  them ;  for  fourteen  efforts  had  now 
been  made  without  any  promise  of  success. 

The  case  then  presented  itself  in  the  following  aspect.  Here 
was  a  patient  whose  exsanguinated  condition  and  tendency  to  pro- 
fuse hemorrhages  demanded  relief  from  an  evil  that  would  soon 
destroy  her  life,  which  on  more  than  one  occasion  had  been  in 
danger  from  excessive  flooding.  Taxis  had  been  tried  fourteen 
times,  some  efforts  lasting  from  five  to  six  hours,  and  only  one  less 
than  an  hour.  The  constriction  which  resisted  reduction  had  been 
cut  at  infinite  risk,  and  all  had  failed.  The  only  recognized  opera- 
tion which  now  offered  itself  was  amputation,  and  at  the  thought 
of  this  the  patient  revolted. 

Under  these  circumstances  I  proposed  an  operation  which 
throughout  the  progress  of  the  case  I  had  kept  in  reserve,  and 
which,  two  years  before  it,  I  had  fully  elaborated  in  my  mind.  It 
was,  that  I  should  make  an  incision  two  inches  in  length  through 
the  abdominal  walls  and  peritoneum,  just  over  the  cervical  ring ; 
pass  into  this  ring  a  steel  dilator,  made  on  the  principle  of  a  glove- 
stretcher  ;  stretch  the  constriction ;  and  return  the  uterus  to  its 
place.  The  propriety  of  the  operation  being  concurred  in  by  my 
colleagues,  it  was  explained  to  Mr.  B.,  and  all  its  important  bear- 
ings made  clear  to  the  patient  herself,  of  whom  I  had  seen  enough 

•  Mai.  de  1' Uterus,  p.  906. 


444 


INVERSION    OF    THE    UTERUS. 


to  know  that  her  unflinching  courage  was  equal  to  any  trial  which 
promised  release  from  the  unfortunate  state  which  for  nearly  two 
years  had  embittered  her  life  and  destroyed  her  usefulness. 

After  ligation  of  the  circular  artery,  the  mucous  membrane  of 
the  uterus  sloughed  extensively,  and  the  patient  ajipeared  much 
exhausted.  In  a  week  from  this  time,  however,  she  was  in  a  fit 
condition  for  the  operation  proposed,  and  it  was  appointed  to  take 
place  on  the  16th  of  September. 

An  instrument  very  similar  to  that  represented  in  Fig.  139  was 
promptly  executed  for  me  by  Messrs.  Darrow  &  Co.,  and  I  ob- 
tained a  small  anal  speculum,  and  a  dilator  for  stricture  of  the  rec- 
tum, to  be  employed,  should  sufficient  dilatation  not  be  accomplished 
by  the  instrument  alluded  to. 

The  selection  of  these  instruments  was  of  course  based  upon 
theoretical  ideas  of  the  requirements  of  the  case.  As  the  sequel 
proved,  they  were  unequal  to  them,  and  a  good  deal  of  difficulty 
was  experienced  in  consequence  of  their  inefficiency. 

On  tlie  16th  of  September  the  operation  was  performed.  The 
patient  having  been  put  under  the  influence  of  ether,  Dr.  Metcalfe 
introduced  his  hand  into  the  vagina,  and  lifted  the  uterus  so  that 
I  could  detect  the  cervical  ring  against  the  abdominal  wall.    I  then 


Fig.  138. 


Replacement  of  uterus  by  dilatation  through  abdomen. 


slowly  cut  down  upon  the  median  line,  as  for  an  exploratory  inci- 
sion in  ovariotomy,  and,  leaving  the  wound  exposed  to  the  air  until 
all  oozing  had  ceased,  cut  into  the  peritoneum.  I  then  inserted 
my  finger  into  the  uterine  sac,  and  found  no  adhesion  whatever  to 


METHODS    OF    EEPLACING    THE    UTERUS.  445 

exist.  Replacing  Dr.  Metcalfe's  hand  Ly  my  left  Land,  I  now  in- 
serted the  steel  dilator,  and,  in  the  manner  represented  in  Fig.  138, 
dilated  the  stricture. 

The  dilatation  was  exceedingly  easy  and  rapid,  hut  I  found  that 
as  I  withdrew  the  dilator,  the  tissue  of  the  organ  would  at  once 
contract.  After  dilating  the  stricture  fully,  I  partially  returned 
the  uterus,  after  some  effort,  in  the  same  manner  in  which  reduc- 
tion was  accomplished  in  a  previous  case.  Drawing  it  down  to 
the  vulva,  I  rapidly  pushed  it  up,  and  was  gratified  at  finding  that 
it  was  nearly  replaced.  Drawing  it  doAvn  again,  this  time  outside 
of  the  hody,  I  discovered  that  the  artery,  cut  one  week  before, 
was  spouting  freely.  I  now  saw  that  success  must  be  attained  at 
once,  or  that  it  would  elude  my  grasp  when  just  within  it.  Actu- 
ated by  this  feeling,  I  rapidly  returned  the  organ,  and  was  delighted 
to  find  one  horn  rise  into  place.  But  the  additional  force  employed 
was  a  little  more  than  the  vagina  could  bear,  and  one  finger  passed 
through  between  the  uterus  and  bladder.  One  horn  was  still  in- 
verted. Passing  the  dilator  into  this,  I  stretched  it  open,  and 
instantly  the  uterus  resumed  its  normal  position. 

The  time  of  the  operation  was  noted  l)y  Dr.  Samuel  W.  Francis 
as  follows :  patient  under  ether,  1  hour  and  2  minutes ;  time  occu- 
pied in  opening  peritoneum,  19  minutes;  time  occupied  in  returning 
uterus,  27  minutes. 

After  this  the  patient  rallied  rapidly,  and  her  delight  at  learning 
that  the  obstinate  inversion  had  been  really  overcome  unquestion- 
ably acted  as  a  stimulant  to  recovery. 

The  abdominal  wound  was  closed  by  four  silver  sutures,  involv- 
ing the  peritoneum,  and  dressed  with  cold  water.  The  vaginal 
rent  was  not  interfered  with. 

On  the  next  day  the  artery,  which  had  already  given  so  much 
trouble*,  began  to  give  forth  blood  so  freely  into  the  vagina  and 
through  the  vaginal  rent  into  the  peritoneum,  that  I  thought  the 
hemorrhage  would  end  fatally.  The  pulse  ran  up  to  160  to  the 
minute,  the  face  and  extremities  became  cold,  and  so  imminent 
did  the  danger  of  exhaustion  appear  to  me  that  all  preparations 
were  made  for  transfusion. 

Before  resorting  to  this  measure,  T  tried  to  check  the  flow  by 
elevating  the  foot  of  the  bed  two  feet,  so  as  to  throw  the  whole 
aortic  column  of  blood  back  upon  the  heart,  and  applied  a  bag 
tilled  with  tannin  against  the  os  uteri.  These  measures  happily 
succeeded,  and  hemorrhage  ceased  entirely. 


446  INVERSION    OF    THE    UTERUS. 

Subsequent  to  this  period,  the  patient  recovered  without  a  single 
unfavorable  sign;  the  peritoneal  edge  of  the  abdominal  wound 
healed  by  first  intention,  and  on  the  eighth  day  after  the  operation 
she  left  her  bed  for  the  lounge. 

This  operation  was  by  no  means  perfect.  The  instruments  which 
I  employed  for  dilatation  were,  I  found  too  late,  inefficient,  and 
means  for  keeping  open  the  constriction,  after  removal  of  the  dilator, 
were  entirely  wanting.  I  feel  very  sure  that  were  I  to  essay  it 
asrain,  which  I  should  not  hesitate  to  do  in  a  ease  which  had  resisted 
all  minor  means^  as  taxis,  vaginal  j^i'^ssvre,  etc.,  and  for  which  no 
resource  but  amputation  remained,  I  should  succeed  more  rapidly, 
easily,  and  with  less  risk  to  my  patient. 

In  reading  the  description  of  such  an  operation  as  this,  the  first 
idea  which  is  likely  to  take  possession  of  the  mind  is  that  of  its 
being  an  unwarrantably  bold  procedure.  This  I  think  is  an  error, 
when  its  dangers  are  compared  with  those  of  amputation.  Ex- 
plorative incisions  for  ovariotomy  prove  that  the  dread  which  was 
formerly  entertained  about  opening  the  peritoneum  was  much 
greater  than  it  should  be.  And  if  the  reader  will  l)ear  in  mind 
the  statistics  already  given,  which  prove  that  one-third  or  one-fourth 
of  all  operations  for  amputation  of  the  inverted  uterus  end  fatally, 
even  while  essaying,  not  cure,  but  palliation  of  symptoms  at  the 
cost  of  the  uterus  itself,  he  must  admit  that  there  are  good  grounds 
for  questioning  this  conclusion,  arrived  at  without  mature  reflection. 

For  the  credit  of  the  operation,  imperfect  as  it  was,  the  following 
facts  must  be  borne  in  mind  by  the  reader.  The  difficulties  which 
attended  it  were  none  of  them  inherent  to  it,  but  depended  upon 
want  of  experience  as  to  its  various  requirements.  The  patient 
was  subjected  to  it  in  a  state  of  great  exhaustion  from  other  opera- 
tions. The  evils  which  followed  it,  and  wellnigh  frustrated  its 
results,  were  due,  not  to  it,  Init  to  section  of  the  neck,  performed  a 
week  before,  and  to  accidental  rupture  of  the  vagina,  which  is  not 
rare  as  a  result  of  manipulation  by  tlie  ordinary  method  of  taxis. 
So  far  as  the  operation  itself  was  concerned,  the  patient  recovered 
without  an  untoward  symptom. 

In  five  weeks  the  patient  returned  to  Kentucky,  where  she  re- 
mained perfectly  well  in  every  respect.  She  informed  me  by  letter, 
after  some  months,  that  she  had  gained  so  much  flesh  that  I  would 
not  be  able  to  recognize  her,  that  her  menstrual  function  was  per- 
fectly normal,  and  that  she  had  no  disagreeable  symptoms  remain- 
ing. About  a  year  after  the  operation  she  became  pregnant  and 
advanced  without  any  noteworthy  symptom  to  the  eighth  month 


METHODS    OF    REPLACING    THE    UTERUS.  447 

of  utero-gestatioii.  At  this  time,  as  I  am  informed,  after  eating 
some  oysters,  imported  from  tlie  Eastern  States  in  a  tin  can,  she  was 
suddenly  affected  hy  the  sjaiiptoms  of  cholera  morbus,  and  died 
within  twenty -four  hours. 

Since  this  time  I  have  met  with  but  one  case,  in  which  I  have 
felt  justified  in  repeating  this  procedure,  and  this,  although  it 
demonstrated  more  completely  than  the  first  the  perfect  simplicity 
and  efficiency  of  the  method,  as  far  as  concerns  its  mechanical 
features,  unfortunately  terminated  fatally  from  peritonitis. 

Case  2. — Mrs.  M.,  an  Irish  woman,  8et.  23,  in  the  lower  walks 
of  life,  was  delivered  eight  months  before  I  saw  her.  The  delivery 
was  natural  up  to  the  third  stage,  but  at  this  time  violent  hemor- 
rhage occurred.  After  delivery  of  the  placenta  this  continued, 
and  during  the  fortnight  succeeding  labor,  the  patient  declared  that 
Bhe  very  nearly  flooded  to  death.  Gradually  this  profuse  flow  ceased, 
or  rather  diminished  very  nmch,  and  she  left  her  bed,  and  resumed 
her  avocations.  Ever  since  her  delivery,  however,  Mrs.  M.  had 
had  menorrhagia  and  metrorrhagia  with  very  few  intervals  of 
cessation,  and  when  I  saw  her  she  was  exsanguinated  to  an  alarming 
degree,  excessively  pallid,  and  apparently  quite  weak.  The  patient 
was  put  under  my  care  by  Dr.  Olcott,  of  Brooklyn,  who  had  been 
called  to  her  about  two  months  before  I  saw  her,  and  had  then 
made  the  diagnosis  of  inversion.  Dr.  Olcott,  who  had  previously 
treated  tAvo  cases  of  inversion  by  taxis,  one  successfully  and  the 
other  unsuccessfully,  placed  her  under  my  care  for  the  purpose  of 
having  this  operation  performed,  as  he  had  exhausted  the  ordinary 
means,  elastic  pressure  and  taxis,  without  avail.  His  last  effort 
had  been  a  very  persistent  one,  and  was  continued  by  himself  and 
two  associates,  who  frequently  replaced  him,  for  two  hours.  After 
this,  the  patient  came  so  near  dying  from  peritonitis,  that  the 
Doctor  did  not  wish  to  repeat,  or  have  repeated,  these  attempts. 

I  operated  in  the  presence  of  Drs.  Olcott,  James  L.  Brown, 
Ilallam,  Walker,  Fisk,  and  Yermilye.  The  patient  having  been 
etherized  and  laid  upon  a  table  covered  with  blankets,  I  made  an 
incision  two  inches  long  through  the  median  line,  and  gradually 
cut  into  the  peritoneum.  Introducing  one  finger  into  the  sac  of 
the  inverted  uterus,  I  inserted  the  dilator,  and  in  sixteen  minutes 
withdrew  it,  and  with  an  ease  which  surprised  us  all,  replaced  the 
uterus.  The  body  did  not  at  once  go  into  its  place,  but  as  I  with- 
drew the  dilator  about  one  inch  of  the  neck  reinverted  itself.  I 
then  replaced  the  dilator,  stretched  the  next  point  of  constriction 
very  gently,  and  at  once  another  inch  or  thereabout  was  returned, 


448  INVERSION    OF    THE    UTERUS. 

and  thus  inch  by  inch  all  was  returned  except  the  right  horn.  A 
few  minutes  of  gentle  stretching  soon  allowed  this  to  pass  into 
place,  and  the  operation  was  completed.  The  abdominal  wound 
was  closed  with  silver  sutures,  and  the  patient  given  ten  drops  of 
Magendie's  solution  by  the  hypodermic  syringe,  and  put  to  bed. 
As  she  had  resisted  all  persuasions  to  enter  my  service  in  the 
Stranger's  Hospital,  Dr.  Vermilye  very  kindly  consented  to  remain 
at  her  house  and  watch  her,  as  no  one  in  her  family  could  be  relied 
upon.  She  did  perfectly  well  for  forty-eight  hours,  but  at  the 
expiration  of  that  time  peritonitis  developed  itself,  and  proceeded 
to  a  fatal  issue. 

This  case,  although  ending  thus,  demonstrated  to  my  satisfaction 
that  the  mechanical  features  of  this  operation  are  all  that  could  be 
desired.  The  yielding  of  the  cervical  ring  under  gentle  distention 
was  easy  and  rapid,  and  return  of  the  inverted  body  equally  so. 

I  have  neither  the  desire  nor  intention  of  entering  into  any 
special  pleading  for  the  procedure  which  I  have  described,  for  I 
am  perfectly  willing  to  let  it  stand  or  fall  upon  its  merits.  If  it 
really  be  what  I  sincerely  believe  it  to  be,  it  will  surely  take  its 
stand  as  a  useful  surgical  resource.  If  I  be  mistaken  in  its  value, 
I  shall  cheerfully  acquiesce  in  its  condcnniation.  Bel'ore  leaving 
the  subject,  it  would  be  well  for  me  to  keep  before  the  reader's 
mind  certain  facts  connected  with  it. 

This  procedure,  let  it  be  remembered,  is  not  offered  as  a  method 
of  treating  inversion  of  the  uterus,  but  as  a  substitute  for  amputa- 
tion. Few  cases  will,  I  think,  resist  elastic  pressure  and  judicious 
taxis ;  but  that  some  will  do  so  cannot  be  ^questioned.  It  is  to 
save  these  few  cases  from  amputation  that  I  suggest  abdominal 
section. 

One  of  the  cases  operated  on  in  this  way  has  proved  fatal.  Let 
it  not  be  forgotten  that  a  certain  number  of  those  cases  treated  by 
elastic  pressure  and  by  taxis  likewise  do  so,  for,  as  in  my  second 
case,  these  operations  are  often  performed  upon  exsanguinated 
women  whose  blood  is  impoverished.  One  instance  of  death  after 
reduction  by  elastic  pressure  is  recorded  by  Dr.  Tait  in  the  eleventh 
volume  of  the  London  Obstetrical  Transactions,  while  one  of  the 
earliest  cases  on  record  reduced  by  taxis,  that  of  Dr.  White,  of 
Buffalo,  likewise  ended  fatally. 

If,  like  the  first  here  recorded,  a  case  should  prove  rebellious  to 
taxis  repeatedly  and  intelligently  applied,  and  to  prolonged  and 
powerful  elastic  pressure,  what  is  to  be  done  ?  Only  two  courses 
have  until  this  time  been  open  to  us;  one  to  leave  the  case  unre- 


METHODS    OF    AMPUTATING.  449 

lieved,  the  other  to  perform  amputation.  In  an  elahorate  report 
of  cases  of  inversion  given  in  the  American  Journal  of  Obstetrics 
for  August,  1868,^  the  results  in  fifty-eight  cases  of  amputation  are 
given.  By  this  statement  it  will  be  seen  that  nearly  one-third  of 
all  operated  upon  died,  and  let  it  not  be  forgotten  that  this  number 
died,  not  in  being  cured,  not  in  an  efl:brt,  even,  at  attaining  perfect 
healtli,  but  in  an  attempt  at  purchasing  immunity  from  a  series  of 
dangerous  and  annoying  symptoms  at  the  price  of  that  organ  of 
which  Hippocrates  says,  "Propter  uterum  est  mulier." 

We  know  that  ordinarily  a  short  incision  made  through  the 
peritoneum  is  not  excessively  dangerous,  consequently  the  question 
which  suggests  itself  to  the  operator  about  to  amputate  is  this:  is 
it  best  to  remove  the  uterus,  the  woman  standing  a  little  more  than 
two  chances  out  of  three  for  life,  and  with  a  certainty  of  sterility 
and  all  those  difliculties  in  the  future  which  are  the  consequences 
of  amenorrhcea,  or  at  least  of  very  imperfect  menstruation;  or  is 
it  best  to  incur  the  risks  of  a  short  abdominal  section,  with  the 
almost  certainty  of  successfully  replacing  the  inverted  uterus  and 
preserving  it  for  the  future  performance  of  its  functions  ? 

Should  abdominal  section  be  selected,  I  should  advise  the  use  of 
the  dilator  represented  in  Fig.  139. 

Fig.  139. 


G.  T/EMANN  & 


This  should  be  very  gently  applied,  not  for  the  dilatation  of  the 
whole  cervical  canal,  but  for  its  upper  extremity  only.  As  soon 
as  that  is  stretched  and  an  inch  or  so  of  the  cervix  returned,  it 
should  be  reapplied  and  another  portion  stretched.  Then  a  little 
more  of  the  inverted  tissue  will  return.  And  thus  inch  by  inch 
the  whole  uterus  should  be  replaced. 

Methods  of  Amjmtatiiig. — Although  it  cannot  be  denied,  that 
instances  may  present  themselves  in  which,  from  impossibility  of 
returning  the  inverted  uterus,  removal  of  the  whole  organ  is  indi- 
cated, it  is  equally  undeniable  that  the  operation  has  been  resorted 
to  very  often  upon  insufficient  grounds  and  before  eflJbrts  at  reduc- 
tion had  been  fairly  tried.    Tyler  Smith  succeeded  after  persevering 

'  Translated  from  the  "Beitraege  zur  Geburtskunde  und  Gynakologie."^ 
29 


450  INVERSION    OF    THE    UTERUS. 

with  elastic  pressure  for  eight  days,  and  Dr.  F.  A.  Ramsay,^  of 
Knoxville,  Tennessee,  after  seventeen  or  eighteen  days  of  effort. 
Does  any  one  doubt  that  in  the  hands  of  many  less  persevering 
practitioners  both  these  cases  would  have  been  treated  by  amputa- 
tion before  success  was  attained?  Amputation  of  the  inverted 
uterus  will  surely  be  less  frequently  performed  in  the  future  than 
it  has  been  in  the  past.  It  is  destined  to  assume  among  operative 
procedures  its  proper  place  as  a  last  resort.  In  addition  to  its  own 
manifest  and  inherent  dangers  it  must  ever  present  these  great  ob- 
jections: 

1st.  Hernia  of  the  abdominal  or  pelvic  viscera  may  have  taken 
place  into  the  inverted  sac ; 

2d.  It  frequently  produces  emansio-mensium  and  its  train  of  evils ; 

3d.  It  necessarily  results  in  sterility. 

It  is  impossible  to  conceive  of  circumstances  which  would  justify 
the  procedure  before  full  consultation  with  the  most  able  counsel 
attainable. 

Removal  of  the  uterus,  although  attended  by  great  danger,  often 
ends  in  recovery.  This  will  not  be  wondered  at  when  it  is  borne 
in  mind  that  even  tearing  away  of  the  organ  lias  been  several  times 
recovered  from.  Radford,  J.  0.  Clarke,^  and  others  have  reported 
cases  in  which  an  inverted  uterus  has  sloughed  otf  from  strangula- 
tion without  a  fatal  issue,  and  Osiander  for  many  years  showed  a 
patient  in  his  lecture-room  from  whom,  after  delivery,  the  midwife 
tore  away  not  only  the  placenta  but  the  inverted  uterus  to  which  it 
was  attached.  A  case  of  similar  kind  is  recorded  in  the  Gazette 
des  Hopitaux  for  1842.  One  child  being  born,  the  midwife  felt 
the  breech  of  another  as  she  su[)posed.  Around  it  she  passed  a 
handkerchief,  pulled  with  all  her  force,  and  dragged  away  uterus 
and  annexpe.     The  patient  recovered ! 

A  very  comprehensive  view  of  the  results  of  amputation  is  i)re- 
sented  us  by  Dr.  West  in  the  following  table : 


K 

ccovered. 

Died. 

Operation 
abandoned. 

Uterus  removed  by  ligature        .... 

45 

.33 

10 

2 

"             "          "   knife  or  ecrasour  . 

5 

3 

2 

"             "          "    knife   or   ecraseur,  preceded 

by  the  ligature 

9 

6 

3 

59  42  15 


Out  of  58  cases  of  amputation  collected  in  the  report  in  the  Ger- 
man journal  recently  alluded  to,  18  were  fatal — nearly  one-third. 


Taylor,  op.  cit.  *  Dublin  Journal,  1837. 


METHODS    OF    AMPUTATING.  451 

Should  it  be  deemed  advisable  to  resort  to  this  procedure  in  spite 
of  the  dangers  incident  to  it,  there  are  three  methods  by  which  it 
may  be  performed :  the  knife,  preceded  by  the  ligature ;  the  ^cra- 
seur,  preceded  by  the  ligature ;  and  galvano-cautery. 

Experience  proves  that  removal  of  an  inverted  uterus  by  the 
knife,  or  even  the  ecraseur,  is  likely  to  be  followed  by  profuse  and 
dangerous  hemorrhage.  To  avoid  this,  a  method  advised  by  Dr. 
McClintock,  of  Dublin,  should  invariably  be  adopted.  It  consists 
in  the  application  of  a  strong  ligature  for  from  two  to  three  days 
before  the  operation.  This  obliterates  the  vessels,  and,  just  about 
the  time  that  decomposition  of  the  strangulated  organ  begins,  it  is 
amputated.  Even  when  galvano-cautery  is  employed,  although 
this  method  is  not  likely  to  be  followed  by  hemorrhage,  it  is  well 
to  surround  the  neck,  above  the  point  at  which  the  wire  is  to  pass, 
by  Hicks's  wire  rope  ecraseur,  in  order  that  compression  may  at 
once  be  made  in  case  it  should  take  place. 

Should  the  stump  remaining  after  removal  by  any  method  show 
signs  of  hemorrhage,  the  white-hot  iron  should  be  passed  over  its 
surface  through  the  speculum.  To  do  this  eifectually,  however,  it 
must  be  secured  before  removal  of  the  uterus,  by  some  means  by 
which  it  can  be  drawn  down.  This  may  be  accomplished  either 
l)y  the  ligature  or  the  wire  ecraseur.  A  tampon  should  be  avoided, 
lest  blood  collecting  above  it  might  separate  the  lips  of  the  wound 
and  enter  the  peritoneal  cavity. 

Removal  of  the  uterus  by  ligature  alone  should  never  be  at- 
tempted. ISTot  only  have  we  better  and  safer  means;  statistics 
prove  this  to  be  an  especially  dangerous  method.  Out  of  33  cases 
thus  operated  upon,  17,  over  half,  ended  fatally. 


452  PEKIUTERINE    CELLULITIS. 


CHAPTER    XXVII. 

PEKIUTERINE  CELLULITIS. 

History. The  history  of  this  aftection  presents   one  of  those 

examples,  which  are  often  repeated  in  medical  literature,  of  a  sub- 
ject which  was  once  understood  being  subsequently  completely 
overlooked  and  forgotten. 

There  can  be  little  doubt  that  it  is  to  this  disease  that  allusion 
was  made  by  Archigenes,  who  flourished  in  the  second  century, 
and  whose  account  of  it  was  subsequently  repeated  by  Oribasius 
in  the  fourth,  and  Aetius  and  Paul  of  ^gina  in  the  sixth  and 
seventh.  The  last  two  unquestionably  refer  to  it  under  the  head 
of  "Abscess  of  the  Womb,"  for  in  one  passage  Paulus  especially 
speaks  of  cases  in  which  the  "  aposteme  is  seated  about  the  mouth 
of  the  uterus." 

The  modern  history  of  the  subject  may  be  thus  stated: 

Described  by  Richard  Wiseman,'  England,  as  "  Dis- 
tempers of  the  uterus  in  cliildhed,"       .     1G79 

«  "      Nichs.  Puzos.-' France,  "Di'pots  Laiteux,"     1V43 

"  "      Bourdon,  a  pupil  of  Recamier,  '•  Fluctu- 

ating tumor  of  true  pelvis,"  .         .     1841 

'*  "      Dohert}^,    Ireland,   '^  Clironic   inflamma- 

tion of  tlic  appendages  of  uterus,"         .     1843 

"  "      Marchal  de  Calvi,  "  Intra-pelvic  phleg- 

monous abscess,"  ....     1844 

"  "      Churchill,'     Ireland,    as    "Abscess     of 

uterine  appendages,"    ....     1844 

«  "      Lever,  England, 1844 

It  will  thus  be  seen  that  after  being  appreciated,  then  entirely 
forgotten,  then  for  a  second  time  brought  into  notice,  the  knowledge 
of  this  afl:ection  languished  for  nearly  two  centuries,  to  be  suddenly 
restored  by  the  eftbrts  of  four  investigators  who  entered  the  field 

'  McClintock,  "  Diseases  of  "Women."  p.  1. 

*  Drs.  West  and  McClintock  date  the  appearance  of  Pnzos,  "  Traite  d'Accoache- 
ment,"  1759.    They  are  probably  in  error,  as  Bernutz  and  Nonat  both  date  it  1743. 
'  West,  "  Diseases  of  Women,"  Am.  ed.,  p.  310. 


ANATOMY.  453 

almost  simultaneously.  It  would  be  unjust  to  a  conscientious 
observer,  M.  Auguste  Nonat,  not  to  mention  the  great  influence 
which  his  writings  have  had  in  advancing  our  knowledge,  but 
when  he  commenced  his  investigations  in  Hopital  Cochin,  in 
1846,  the  morbid  state  which  he  subsequently  did  so  much  to 
elucidate,  had  already  received  considerable  attention  in  Great 
Britain. 

Dejiniiion,  Synonyms^  and  Frequency. — This  disease,  which  is  now 
known  to  be  one  of  frequent  occurrence,  consists  in  an  inflammation 
of  the  adipose  and  areolar  tissue  lying  behind,  in  front  of,  and  at 
the  sides  of  the  uterus,  and  extending  up  between  the  layers  of 
serous  membrane  which  make  the  broad  ligaments.  It  has  been 
described  by  different  writers  under  the  following  titles  :  parame- 
tritis, periuterine  phlegmon,  inflammation  of  the  broad  ligaments, 
pelvic  abscess,  and  pelvic  cellulitis.  The  last  term,  which  was 
applied  to  it  by  Sir  James  Simpson,  indicates  the  nature  and  seat 
of  the  disease;  but  it  is  open  to  the  grave  objection  of  being  too 
genera]  in  its  application,  and  not  sufficiently  confining  within  pro- 
per limits  a  distinct  and  well-defined  affection. 

Anatomy. — '"  The  sub-peritoneal  pelvic  tissue,"  says  Dr.  Savage, 
in  his  work  on  the  Female  Pelvic  Organs,  "fills  up  all  that  part  of 
the  pelvic  cavity  between  the  pelvic  '  roof  and  floor  of  the  pelvis, 
which  is  not  occupied  by  the  viscera,  and  is  the  sole  bond  of 
union  between  them."  Any  one  can  satisfy  himself  as  to  the 
abundance  of  loose  cellular  tissue  in  the  pelvis,  by  even  a  rough 
dissection.  It  will  be  found  in  the  broad  ligaments  in  great 
abundance  separating  their  contents,  between  the  vagina  and  rec- 
tum, the  rectum  and  sacrum,  the  uterus  and  bladder,  the  bladder 
and  abdominal  parietes,  and  investing  the  psoas  and  iliac  muscles. 
The  relations  of  the  urethra  and  rectum  to  this  tissue  are  peculiar, 
each  being  isolated  in  a  sheath  or  canal  which  may  be  removed 
with  ease. 

Everywhere  around  the  pelvic  organs  cellular  tissue  exists 
except  between  the  peritoneum  and  uterus.  Here  so  little  is  dis- 
coverable that  some  have  ventured  to  deny  its  existence,  while 
all  admit  that  over  the  body  of  that  organ  it  is  difiicult  of  demon- 
stration. Dr.  Farre^  declares  that  along  the  median  line  and  over 
the  whole  fundus  he  has  found  the  peritoneum  inseparable  from 
the  uterus,  except  after  prolonged  maceration.  On  the  sides  of 
the  organ  and  at  the  cervix  the  connection  is  not  so  intimate. 


Savage,  op.  cit.  ^  Cyc.  Anat.  and  Phys.,  Sup.,  p.  631. 


454  PEEIUTERINE    CELLULITIS. 

loose  cellular  tissue  existing  at  these  points  to  such  an  extent  as 
to  permit  of  the  investing  membrane  gliding  upon  the  uterus.  M. 
Goupil,'  who  has  made  a  special  study  of  this  tissue,  declares  that 
it  is  so  small  in  amount  at  the  point  of  contact  of  the  peritoneum 
and  vagina,  and  in  front  and  rear  of  the  uterus,  that,  "  its  presence 
can  scarcely  be  determined." 

PcUhology. — According  to  the  wide  range  given  to  the  affection 
by  the  majority  of  English  pathologists,  this  tissue  is  the  seat  of 
the  disease  under  consideration,  which  may  affect  any  or  all  of  its 
parts.  Drs.  West,  Simpson,  and  most  British  writers,  except  Dr. 
Benuet,  adopt  this  view  and  regard  as  instances  of  the  affection 
any  inflammation  of  the  cellular  tissue  within  the  pelvis.  But  this 
evidently  leads  to  great  confusion.  It  is  certainly  not  conducive 
to  clearness  of  comprehension  lo  blend  the  description  of  iliac, 
psoas,  and  perirectal  abscesses  with  this  disease. 

French  writers,^  on  the  contrary,  regard  as  instances  of  peri- 
uterine cellulitis  only  inflammation  of  the  cellular  tissue  of  the 
broad  ligaments  and  of  that  immediately  in  contact  with  the 
uterus  at  its  junction  with  the  vagina  and  bladder.  While  admit- 
ting that  inflammation  originating  here  may  spread,  by  continuity 
of  structure,  to  other  areolar  tracts  in  the  jielvis,  they  regard  these 
as  complications,  designating  them  by  different  appellations,  and 
do  not  admit  them  as  elements  of  this  affection.  This  is  the 
definition  which  I  would  adopt,  and  to  express  it  clearly  have 
employed  the  term  periuterine,  in  place  of  pelvic,  cellulitis. 

Periuterine  cellulitis  has  three  stages:  1st,  the  stage  of  active 
congestion;  2d,  that  of  effusion  of  liquor  sanguinis;  3d,  that  of 
suppuration.  In  its  course  it  may  be  likened  to  an  ordinary  fur- 
uncle ;  at  first  there  is  simple  congestion  accompanied  by  pain, 
heat,  and  swelling ;  then  liquor  sanguinis  is  effused,  which  creates 
hardness  and  tension,  and  lastly  suppuration  occurs,  and  ends  the 
morbid  process,  unless  one  of  two  other  terminations  take  place. 
Resolution  may  occur,  or,  in  place  of  suppuration,  the  areolar 
tissue  involved  may  be  destroyed,  as  it  so  generally  is  in  anthrax 
and  phlegmonous  erysipelas,  and  come  forth  as  a  slougliing  mass. 

The  term  phlegmon,  now  almost  obsolete  with  us,  but  still  in 
use  on  the  continent  of  Eui'ope,  signifying  inflammation  of  areolar 
tissue,  is  strictly  applicable  to  this  aftection.  Its  course  is  similar 
to  that  of  areolar  inflammations  in  other  parts  of  the  body,  and  its 
three  stages  are  identical  with  theirs. 


'  Becquerel,  p.  441,  vol.  i.  2  Aran.  Mai.  de  I'Ut^rus,  p.  675. 


PATHOLOGY.  455 

The  most  common  seat  of  periuterine  cellulitis  is  the  areolar  tis- 
sue of  the  broad  ligaments,  and  generally  that  of  one  side  only  is 
affected. 

In  a  certain  number  of  cases  where  no  affection  of  the  areolar 
tissue  of  the  broad  ligaments  exists,  circumscribed  tumors,  in 
immediate  contact  with  the  womb,  have  long  been  noticed.  Lis- 
franc  supposed  them  to  be  due  to  partial  parenchymatous  metritis, 
"engorgements,"  which  had  resulted  in  enlargements  of  one  part 
of  the  organ,  and  no  one  contradicted  him  until  M.  iNonat,'  about 
the  year  1849,  described  them  as  being  due  to  phlegmonous  inflam- 
mation in  the  areolar  tissue  immediately  around  the  uterus,  i.  e., 
between  the  cervix  and  rectum,  the  cervix  and  bladder,  and  imme- 
diately by  the  side  of  the  neck.  The  existence  of  this  variety  of 
cellulitis  has  been  denied  by  M.  Bernutz,  who  sustains  his  position 
by  abundant  argument.  In  reference  to  it,  I  will  merely  say  here, 
that  there  are,  so  far  as  my  knowledge  extends,  only  two  cases  of 
such  limited  cellulitis  substantiated  by  autopsic  evidence,  one 
reported  by  M.  Demarquay,^  the  other  by  M.  Simon.^  There  are 
many  in  which  abscesses  in  the  broad  ligaments  have  pointed  ante- 
riorly or  posteriorly  to  the  cervix,  but  these  come  within  a  different 
category.  The  broad  ligaments  and  their  entire  contents,  cellular 
tissue,  ovaries,  and  Fallopian  tubes,  are  more  frequently  affected 
than  any  other  parts,  and  M.  Aran  goes  so  far  as  to  say  that  the 
collections  of  pus  occurring  in  periuterine  cellulitis  "belong  more 
particularly  to  the  ovaries  and  tubes."  In  post-mortem  examina- 
tions these  parts  are  often  found  imbedded  in  a  mass  of  effxised 
material,  the  ovaries,  one  or  both,  in  a  state  of  suppuration,  and 
the  tubes  inflamed  and  filled  with  pus,  or  constricted  at  both  uterine 
and  ovarian  extremities  and  dilated  by  sero-purulent  material  so 
as  to  constitute  tubal  dropsy.  I  have  examined  the  post-mortem 
reports  of  cases  by  a  number  of  authorities  with  reference  to  this 
point,  and  rejecting  only  those  in  which  the  examination  was  made 
in  too  careless  a  manner  to  allow  of  their  admission,  I  present  them 
in  the  following  table: 

No.  of  Cases.        Authority.  Seat  of  Purulent  Collection. 

1.  M.  Nonat.  Behind  the  uterus  connecting  with  suppurating 

cyst  in  left  ovary ;  small  abscess  in  right  ovary. 

2.  M.  Nonat.  Between  uterus  and  rectum  extending  into  broad 

ligaments  of  both  sides. 

3.  M.  Nonat.  On  left  side  extending  from  uterus  to  ilium. 

'  Op.  cit.,  p.  237.  «  Gazette  des  H5pitaux.  April  17,  1858. 

^  Bull,  de  la  Soc.  Anat.  de  Paris, 


456 


PERIUTERINE    CELLULITIS, 


No.  of  Cases. 
4. 


Authority. 
M.  Nonat. 


10. 


Dr.  West. 
Dr.  West. 


Dr.  West. 

Dr.  McClintock. 

^I.  Demarquay. 

M.  Simon. 


Seat  of  Purulent  Collection. 
Behind  uterus  and  vagina  extending  into  left 
broad  ligament ;  another  the  size  of  a  hen's 
egg  just  behind  the  uterus,  opening  into  a 
third,  very  large,  extending  to  sigmoid  flexure 
and  into  broad  ligament. 

Left  broad  ligament. 

Opposite  right  sacro-iliac  synchondrosis  under 
psoas  muscle,  another  to  the  left  of  and  behind 
the  rectum. 

Left  broad  ligament. 

Left  broad  ligament. 

In  cellular  tissue  between  uterus  and  rectum  and 
also  in  recto-uterine  pouch  of  peritoneum. 

Size  of  a  small  orange,  between  the  bladder  and 
uterus,  sending  conoidal  prolongation  into  left 
broad  ligament.  Its  limits  were  as  follows : 
base  of  bladder  in  front ;  neck  and  body  of 
uterus  behind ;  peritoneum  above ;  vagina 
below :  at  the  sides  it  ran  off  into  the  broad 
ligaments. 

Left  broad  ligament. 

Left  ovary,  right  tube,  with  pelvic  adhesions 
throughout. 

Size  of  an  apple  in  left  broad  ligament. 

At  side  of  uterus  and  in  the  left  broad  ligament. 

It  will  thus  be  seen  that  of  this  number,  which  is  large  when 
it  is  remembered  that  the  disease  rarely  ends  in  death,  but  two 
cases  present  instances  of  cellulitis,  unconi])licated  bj  disease  of 
the  cellular  tissue  of  the  broad  ligaments,  ovaries,  or  tubes.  One 
of  these,  that  of  Simon,  is  conclusive  of  the  possibility  of  sueli 
disease;  that  of  Demarquay  is  doubtful,  for  with  the  abscess  in 
the  cellular  tissue,  there  was  also  one  in  the  cul-de-sac  of  Douglas. 
The  purulent  collections  in  this  disease  may  be  results  of  morbid 
action  in  the  cellular  tissue,  the  ovaries,  or  the  Fallopian  tubes. 
In  other  words,  with  the  disease  known  as  cellulitis  we  often, 
indeed  generally,  have  other  affections,  some  of  them,  in  the 
present  state  of  our  knowledge,  not  separable  from  it,  which  attend 
upon  it  as  complications. 

Complications.— The  complications  of  periuterine  cellulitis  are — 

Pelvic  peritonitis; 

Ovaritis ; 

Fallopian  salpingitis  ;^ 

Endometritis ; 

Uterine  displacement. 


IL 

M.  Aran. 

12. 

M.  Aran. 

13. 

M.  Bourdon. 

14. 

M.  Aran. 

'  (Ja>.rtiy|,  "a  tube." 


COURSE,   DURATION,   AND    TERMINATION.  457 

The  occurrence  of  these  complications  with  cellulitis  is  so  fre- 
quent that  they  may,  at  least  the  iirst  three,  almost  he  regarded 
as  elements  of  it,  when  it  exists  in  severity.  They  are,  indeed, 
universally  present  where  the  tissue  of  the  hroad  ligaments  is 
seriously  involved,  as  will  be  seen  by  reference  to  autopsic  evidence 
contained  in  any  of  the  works  upon  the  subject.  The  fact  of  the 
frequent  coexistence  of  endometritis  should  be  especially  noted,  for 
great  injury  may  be  done  by  local  treatment  of  it,  under  the  sup- 
position that  it  is  the  cause  of  symptoms  which  in  reality  are  the 
results  of  cellulitis. 

Course^  Duration^  and  Termination. — It  is  necessary  that  I  should 
here  inform  the  reader  that  the  account  which  I  shall  give  of  this 
part  of  our  subject  will  diifer  essentially  from  that  generally  found 
in  systematic  works,  for  the  reason  that,  regarding  pelvic  cellulitis 
and  pelvic  peritonitis,  which  are  usually  treated  of  synonymously, 
as  different  affections,  I  shall  attempt  to  describe  them  separately. 
Cellulitis  proper,  that  is,  uncomplicated  by  other  diseases,  rarely 
passes  into  a  chronic  state,  but  usually  in  the  course  of  two  or  three 
weeks  passes  off  by  resolution  or  ends  in  suppuration,  the  former 
being  much  the  more  frequent  termination.  Any  one  of  its  usual 
complications,  however,  peritonitis,  endometritis,  ovaritis,  or  sal- 
pingitis, may  become  chronic,  and  thus  leave  the  impression 
upon  the  mind  of  the  observer  that  the  original  affection  has  done 
so.  Or  one  or  more  abscesses  may  discharge  themselves  by  long 
sinuses  which  fail  to  allow  of  their  complete  evacuation,  and  may 
continue  to  pour  out  pus  for  months  or  even  years.  In  saying  that 
cellulitis  rarely  becomes  chronic,  I  look  upon  chronic  pelvic  abscess 
rather  as  one  of  its  results  than  one  of  its  stages.  If  the  case  be 
of  acute  character  and  occur  as  a  sequel  of  parturition,  suppuration 
may  take  place  in  a  few  days,  but  ordinarily,  even  under  these 
circumstances,  it  does  not  occur  for  two  or  three  weeks.  In  a 
chronic  case  the  effused  matter  may  remain  hard,  resisting,  and 
ligneous  for  months,  without  showing  signs  of  softening,  but  such 
instances  are  exceptions  to  the  rule.  After  suppuration  has  occurred 
the  disease  may  follow  one  of  three  courses: 

1st.  The  accumulated  pus  may  discharge  itself  and  the  abscess 
gradually  dry  up  and  disappear. 

2d.  The  empty  sac,  lined  by  pyogenic  membrane,  may  for  an 
unlimited  time  go  on  pouring  out  pus. 

3d.  Small  abscesses  may  form  and  discharge  in  one  part,  then 
others  may  do  so  in  another,  until  the  whole  pelvic  areolar  tissue 
is  perforated  by  them  and  by  fistulous  tracts  connecting  them. 


458  PERIUTERINE    CELLULITIS. 

There  are  various  outlets  for  the  imi^risoned  purulent  accumu- 
lation : 

1st.  Through  the  abdominal  walls  or  saphenous  openings ; 

2d.  Through  the  pelvic  viscera,  bladder,  rectum,  vagina,  urethra, 
or  uterus; 

3d.  Through  the  floor  of  the  pelvis  near  the  anus; 

4th.  Through  the  pelvic  foramina,  obturator,  or  sacro-ischiatic ; 

5th.  Through  the  pelvic  roof  into  the  peritoneal  cavity. 

Sometimes  the  purulent  collection  burrows  into  the  surrounding 
tissues  and  evacuates  itself  at  a  distance.  In  one  case  which  I  saw 
with  Dr.  Echeverria,  it  passed  through  the  sciatic  foramen,  and 
burrowing  upwards  and  forwards,  came  forth  near  the  great  tro- 
chanter. It  may  thus  take  so  eccentric  a  course  as  to  mislead  the 
practitioner  as  to  the  seat  of  the  abscess. 

The  most  frequent  channels  of  evacuation  are  the  vagina  and 
rectum,  in  the  non-puerperal  form,  and  probably  the  abdominal 
walls  in  the  puerperal,  or  at  least  the  results  of  Dr.  McClintock's' 
carefully  noted  cases  would  lead  us  to  believe  so.  In  37  i)uerperal 
cases  treated  by  him  which  ended  in  suppuration,  20  abscesses  dis- 
charged in  the  iliac  regions,  2  above  the  pubes,  1  in  the  inguinal 
region,  and  1  beside  the  anus.  Of  the  remaining  13;  6  were  dis- 
charged per  vaginam,  5  per  anum,  and  2  burst  into  the  bladder. 
In  the  non-puerperal  variety  it  is  extremely  rare  for  the  abscess  to 
discharge  externally,  and  fortunately  in  both  forms  it  is  rare  for  it 
to  burst  into  the  peritoneum. 

Prognosis. — A  guarded  prognosis  should  always  be  made  as  to 
the  time  of  recovery,  for  no  amount  of  experience  can  foresee  the 
course  of  the  affection;  whether  the  effused  liquor  sanguinis  will 
disappear  by  absorption  in  three  weeks ;  whether  the  discharge  of 
one  abscess  will  end  the  patient's  suffering;  or  whether  a  chronic 
induration  will  exist  for  a  great  length  of  time.  But  fortunately 
it  may  be  stated,  that  the  prospects  as  to  life  are  decidedly  favor- 
able, though  in  cases  occurring  just  after  parturition,  there  is 
always  some  danger  from  general  peritonitis. 

Causes. — The  disease  usually  occurs  as  a  result  of  one  of  the  fol- 
lowing causes : 

Parturition  or  abortion ; 
Inflammation  of  uterus  or  ovaries  ; 

Direct  injury  from  coition,  caustics,  pessaries,  operations,  or 
blows. 

'  Op.  cit. 


SYMPTOMS.  459 

Parturition  or  abortion  produces,  according  to  statistics,  from 
one-half  to  two-thirds  of  all  the  cases.  Even  this  large  proportion 
I  believe  to  full  short  of  the  truth,  from  the  fact  that  those  collect- 
ing the  statistics  from  which  the  deductions  were  drawn,  made  no 
distinction  between  this  disease  and  pelvic  peritonitis.  Cellulitis 
will  very  rarely  be  met  with  except  after  the  parturient  process. 
It  is  true  that  when  the  puerperal  state  exists  as  a  predisposing 
cause,  exposure  to  cold,  fatigue,  over-exertion,  etc.,  will  excite  it ; 
but  under  these  circumstances  they  are  merely  immediate  and 
exciting  influences. 

Inflammation  of  the  Ovaries  or  Uterus.  It  is  rare  to  meet  with 
the  aftection  in  a  non-puerperal  patient,  as  the  result  of  exposure, 
unless  she  be  suffering  from  disease  of  these  organs.  Aran  believes 
disease  in  the  ovaries  to  be  "  almost  always  the  cause."  It  is  cer- 
tain that  these  organs  are  generally  diseased  where  the  affection 
exists,  but  it  is  difficult  to  determine  whether  as  a  complication, 
or  as  the  first  link  in  the  chain.  In  the  histories  of  fourteen  au- 
topsies which  I  have  collected,  the  state  of  the  ovaries  is  mentioned 
in  ten.  Out  of  these  they  v/ere  affected  by  inflammation  in  seven. 
In  some  of  the  seven  cases,  abscesses  existed  ;  in  others  their  tissue 
was  destroyed,  and  in  others  they  had  entirely  disappeared.  Any 
chronic  or  acute  disease  of  either  the  uterine  parenchyma  or  mu- 
cous lining,  may  also  result  in  it,  and  I  have  more  than  once  seen 
it  follow  applications  of  mild  character  to  the  cavity  of  the  uterus. 

Direct  injury  is  by  no  means  a  rare  cause  in  non-puerperal 
cases,  though  it  generally  proves  active  in  those  suftering  from 
previous  uterine  or  ovarian  disorders.  Thus  it  may  follow  ope- 
rations upon  the  neck  or  body  of  the  uterus,  slitting  the  neck  for 
flexion  or  contraction,  for  example,  or  simple  dilatation  by  a  tent. 
It  may  result  from  efforts  at  removal  of  intra-uterinc  growths, 
and  one  fatal  case  that  I  have  met  followed  the  ligation  of  haemor- 
rhoids. 

The  important  fact,  that  this  disease  is  usually  not  an  idiopathic 
aftection  but  one  symptomatic  of  uterine  or  ovarian  inflammation 
has  been  especially  insisted  on  by  Dr.  Matthews  Duncan,  who  first 
drew  attention  to  it  as  early  as  1853. 

Symptoms. — The  acute  form,  and  more  especially  that  occurring 
after  parturition,  is  usually  ushered  in  by  very  decided  symptoms, 
of  which  the  most  constant  are  the  following : 


460  PERIUTERINE    CELLULITIS. 

Chill ; 

Increased  thermometric  range ; 

Pain ; 

Fever ; 

Dysuria ; 

Metrorrhagia. 

The  chill,  though  sometimes  absent,  is  a  very  general  symptom. 
'No  sooner  does  it  pass  oif  than  the  pulse  rises  to  110  or  120,  in- 
creased heat  is  felt  in  the  hypogastric  region,  and  pain,  which  for 
a  number  of  hours  or  perhaps  days  before  was  just  perceptible, 
comes  on  with,  considerable  violence.  The  thermometer  shows 
marked  increase  of  animal  heat,  rising  to  103°  or  104°,  or,  in  severe 
cases,  even  higher.  With  these  general  symptoms  there  will  be 
others  pointing  to  the  rectum  and  bladder,  and  should  the  affection 
exist  in  a  menstruating  woman  the  flow  may  be  much  increased. 
Even  when  tlie  patient  is  not  menstruating,  uterine  hemorrhage 
sometimes,  though  not  frequently,  comes  on. 

But  he  who  awaits  these  symjjtoms  for  diagnosis  will  be  led  into 
many  errors  of  omission,  for  subacute  cases  very  generally,  and  acute 
cases  sometimes,  fully  develop  themselves  without  them. 

All  cases  may  be  brought  under  three  heads  as  to  severity  of 
symptoms : 

1st.  Cases  accompanied  by  chill,  fever,  pain,  and  ordinary  signs 
of  inflammation ; 

2d.  Those  accompanied  by  pain  without  chill  or  fever; 

3d.  Those  marked  by  scarcely  any  symptoms  except  extreme 
feebleness  and  some  sense  of  pulsation  and  weight  about  the  pelvis, 
with  hectic  fever  towards  evening. 

Cases  which  have  assumed  the  chronic  form  will  present  them- 
selves with  such  a  history  as  this:  a  patient  who  was  delivered 
one,  two,  or  three  months  ago  has  not  recovered  her  strength,  but 
is  very  feeble,  has  no  appetite,  and  feels  nervous,  depressed,  and 
feverish  towards  evening.  She  has  no  absolute  pains,  but  fears 
that  something  is  wrong  about  the  womb,  for  now  and  then  she 
feels  a  sensation  of  throbbing,  tension,  and  weight  about  that 
organ,  which  is  increased  by  defecation,  urination,  and  walking. 
This  prompts  to  physical  exploration,  which  establishes  the  diag- 
nosis. 

Physical  Signs. — Physical  exploration  is  the  means  on  which  we 
must  rely  for  a  rapid  and  certain  determination  of  the  character 
of  these  cases.  Should  the  finger  be  introduced  into  the  vagina 
during  the  first  stage,  the  parts  will  be  found  to  be  very  warm 


PHYSICAL    SIGNS.  461 

and  perhaps  a  swollen  and  oedeinatous  spot  may  be  detected.  Upon 
j)ressing  in  diiierent  directions  great  sensitiveness  will  be  observed, 
and  by  conjoined  manipulation  a  particularly  sensitive  point  will 
be  detected  usually  on  one  side  of  the  uterus. 

As  the  second  stage,  or  stage  of  effusion,  advances,  induration 
occurs  in  the  areolar  tissue  aifected,  and  then,  by  careful  vaginal 
touch  combined  with  external  manipulation,  a  tumor  as  large  as  a 
walnut,  a  goose's  egg,  or  an  orange,  may  be  detected  in  one  of  the 
broad  ligaments,  or  in  the  tissue  around  the  cervix. 

But  the  examiner  must  not  suppose  that  the  mere  introduction 
of  the  finger  into  the  vagina  will  accomplish  a  discovery  wliich 
often  requires  the  greatest  care  and  most  thoughtful  attention  in 
examination.  The  finger  being  passed  up  to  the  cervix  and  the 
other  hand  placed  upon  the  hypogastrium  so  as  to  make  counter- 
pressure,  it  should  be  carefully  pressed  against  Douglas's  cul-de-sac 
and  all  around  the  cervix  over  the  base  of  the  bladder  and  as  far 
as  possible  towards  the  fundus.  Then  it  should  be  made  in  a  simi- 
larly careful  manner  to  traverse  the  sides  of  the  pelvis  where  the 
broad  ligaments  are  placed,  and  last  of  all,  those  parts  below  the 
pelvic  roof.  For  one  sufiiciently  practised  in  this  kind  of  exami- 
nation this  procedure  will  generally  be  sufficient  to  determine  the 
existence  of  even  a  very  small  point  of  induration  on  the  sides  or 
in  front  of  the  uterus.  Sometimes,  where  it  is  posterior  to  that 
organ,  a  rectal  exploration  will  throw  nmch  additional  light  upon 
the  case. 

Should  the  disease  have  advanced  to  its  third  stage,  in  addition 
to  the  signs  already  noted,  the  uterus,  which,  as  already  mentioned, 
is  generally  displaced,  is  now  pushed  from  its  normal  position, 
in  a  direction  opposite  to  the  accumulated  pus.  Sometimes  it  lies 
upon  the  floor  of  the  pelvis,  at  others  it  is  in  a  state  of  anteversion, 
retroversion,  or  lateroversion,  and,  more  rarely,  sharply  flexed,  the 
body  having  remained  movable  after  the  cervix  has  become  fixed. 

Into  whatever  malposition  it  has  been  forced  it  remains  to  a  cer- 
tain extent  immovable,  from  fixation  by  adhesive  lymph.  But 
this  fixation  is  by  no  means  so  complete,  so  universal,  as  in  pelvic 
peritonitis,  I  feel  satisfied  that  I  have  seen  two  unquestionable 
cases  in  which  no  fixation  of  the  uterus  existed  at  all.  This,  how- 
ever, is  very  rare.  Nonat  has  even  gone  so  far  as  to  declare  that 
the  phlegmonous  mass  itself  may  be  movable,  and  Dr.  Duncan, 
reports  one  case  which  appears  to  verify  this  statement.  I  have 
never  seen  an  instance  in  which  this  mass  was  not  firmly  fixed. 


462  PERIUTERINE    CELLULITIS. 

Differentiation.— The  diseases  with  which  it  may  be  confounded 
are — 

Fibrous  tumors; 
Hematocele ; 
Pelvic  peritonitis. 

Fibrous  tumors  are  x^ainless,  free  from  tenderness,  and  movable 
in  the  pelvis.  They  are  unaccompanied  by  chill,  fever,  and  other 
signs  of  inflammation,  and  are  closely  attached  to  the  uterus,  so  as 
to  form  part  of  it.  The  tumors  resulting  from  cellulitis  are  the 
contrary  of  all  this,  and  appear  firmly  attached,  like  bony  growths, 
to  the  walls  of  the  pelvis. 

Hematocele  occurs  suddenly  with  uterine  hemorrhage,  and  is 
marked  by  prostration,  coldness,  and  other  symptoms  of  loss  of 
blood.  The  tumor  created  is  soft  in  the  beginning  and  grows 
hard;  that  of  cellulitis  is  hard  in  the  beginning  and  tends  to 
softening. 

Pelvic  peritonitis  shows  the  ordinary  signs  of  peritoneal  inflam- 
mation, great  tendency  to  relapse  at  menstrual  periods,  excessive 
pain  and  tenderness,  and  produces  no  distinct  tumor  in  the  begin- 
ning, but  hardening  of  the  whole  pelvic  roof.  Later,  a  small  tumor 
may  be  discovered,  but  it  is  usually  posterior  to  the  uterus  and 
not  on  one  side  of  it.  The  uterus  is  less  movable  than  in  cellu- 
litis, and  when  the  body  is  fixed  the  cervix  sometimes  moves  under 
pressure. 

Consequences  of  Cellulitis. — The  remote  results  of  this  aflfcction 
are  so  grave,  that  even  if  there  were  no  dangers  immediately  con- 
nected with  it,  they  would  stamp  its  occurrence  as  a  great  disaster. 
The  ovaries  are  at  times  destroyed  l)y  suppurative  action;  at  others 
they  undergo  an  atrophy,  the  result  of  inflammation,  and  the 
Fallopian  tubes  are  often  left  impervious.  The  uterus  is  often 
permanently  displaced  in  consequence  of  strong  adhesions  which 
bind  it  in  a  bad  position.  From  this  results  the  fact,  that  although 
the  disease  be  cured,  the  patient  is  often  left  incapacitated  for  some 
of  the  most  important  physiological  functions.  Sterility,  amenor- 
rhoea,  dysmenorrhoea,  menorrhagia,  tubal  dropsy,'  and  displace- 
ment may  remain  to  attest  the  gravity  of  the  original  disease,  and 
continue  for  an  unlimited  time  a  source  of  suffering  for  the  patient 
and  discouragement  for  the  physician. 

Treatment. — Should  the  practitioner  be  called  in  the  acute  stage, 
before  effusion  has  occurred,  or  after  its  occurrence  and  before  its 

'  Aran,  op.  cit.,  p.  638. 


TEEATMENT.  463 

complete  organization,  leeches  should,  in  the  case  of  a  strong 
patient,  he  at  once  applied  over  the  hypogastrium.  After  leeching, 
warm  poultices  of  powdered  flaxseed  should  be  applied  every 
third  or  fourth  hour  over  the  hypogastrium,  the  bowels  kept  con- 
stipated, and  febrile  action,  should  it  exist,  be  quieted  by  refrige- 
rants and  direct  sedatives,  as  tincture  of  veratrum  viride,  tincture 
of  aconite,  or  tincture  of  gelseminum.  The  patient  should  at  the 
same  time  be  brought  under  the  quieting  influence  of  opium,  which 
throughout  the  acute  stage  of  the  aflection  should  be  steadily  kept 
up.  It  accomplishes  these  results:  it  relieves  pain,  diminislies  the 
severity  of  the  inflanmiatory  process,  keeps  the  bowels  constipated, 
produces  sleep,  and  creates  general  nervous  quietude.  If  when  first 
seen  the  patient  be  suflPering  very  severely,  ten  drops  of  Magendie's 
solution  of  morphia  may  be  injected  by  the  hypodermic  syringe 
into  the  cellular  tissue  of  the  arm. 

Absolute  rest  should  be  enjoined,  the  patient  not  being  allowed 
to  sit  up  in  bed  for  a  moment,  upon  any  pretext  whatever.  Were 
I  limited  to  one  remedial  resource  in  this  aflection,  I  should  choose 
this  in  preference  to  all  others,  but  to  accomplish  anything  it  must 
be  absolutely  enforced. 

Tlie  diet  of  the  patient  should  be  mild  and  unstimulating,  con- 
sisting of  milk  with  farinaceous  substances,  and  tea  or  cofl'ee. 

As  soon  as  the  acute  symptoms  have  passed,  and  vaginal  touch 
informs  us  that  the  efliused  material  is  becoming  thoroughly 
organized,  a  further  effort  should  be  made  to  break  up  the  morbid 
train  before  it  passes  on  to  suppuration  or  into  chronic  induration, 
by  the  application  of  a  blister,  six  by  eight  inches,  over  the  hypo- 
gastrium. This  should  not  be  applied  before  febrile  action  and 
the  most  acute  symptoms  have  disappeared.  Some  excellent  au- 
thorities, among  others  Sir  James  Simpson,  object  to  blistering 
for  fear  of  strangury  resulting.  I  have  never  had  to  do  otherwise 
than  congratulate  myself  on  its  employment.  Should  the  case 
tend  to  an  acute  course,  and  suppuration  be  impending,  this  should 
be  encouraged  by  constant  poulticing. 

As  soon  as  the  acuteness  of  the  attack  has  passed,  until  which 
time  attention  should  be  turned  to  quieting  the  general  symptoms 
of  inflammation,  it  is  advised  by  the  best  authorities  that  the  iodide 
or  bromide  of  potassium  should  be  administered,  the  former  in 
five-grain  doses  repeated  every  third  or  fourth  hour,  or  tlie  latter 
in  doses  of  ten,  fifteen,  or  even  twenty  grains,  at  the  same  intervals. 
At  the  same  time  that  I  am  not  prepared  to  deny  the  utility  of 


464  PERIUTERINE    CELLULITIS. 

these  drugs,  I  confess  that  I  have  never  heen  able  to  persuade 
myself  that  they  really  accomplish  any  good  result. 

There  is  no  more  certain  method  of  disgorging  the  veins  of  the 
pelvis  and  lower  bowel  than  by  acting  upon  the  liver,  which  governs 
the  outlet  of  the  portal  system,  with  which  they  are  connected,  and 
this  can  most  readily  be  done  by  mercurial  cathartics.  Thus  occa- 
sionally used,  the  mercurials  prove  of  great  benefit  in  relieving  con- 
gestion, which  is  a  leading  element  of  the  disease.  But  in  doing  this 
we  are  not  developing  the  specific  action  of  these  medicines,  which 
here  act  as  a  subordinate,  and  not  the  chief  element  of  treatment. 
The  production  of  ptyalism  should  be  avoided,  since  it  is  by  no 
means  certain  that  it  is  of  any  benefit,  and  by  impoverishing  the 
blood  at  the  commencement  of  what  may  become  an  exhausting 
disease  it  may  do  absolute  injury.  As  the  acuteness  of  the  aflection 
subsides  the  bowels  should  be  kept  free  by  laxative  medicines,  and 
the  occasional  use  of  a  mercurial  in  this  capacity  is  indicated.  It 
may  be  necessary  to  repeat  the  a]>plication  of  leeches,  and  the 
repetition  of  the  blister  is  often  called  for  before  the  case  ends  in 
suppuration  or  passes  into  the  chronic  stage. 

While  the  patient  remains  in  bed,  warm  poultices,  or  towels 
wrung  out  of  warm  water  and  covered  by  oil  silk,  should  be  worn 
over  the  hj'pogastrium.  An  additional  emollient  remedy  of  great 
value  is  the  persevering  use  of  the  warm  douche  for  fifteen  or 
twenty  minutes,  night  and  morning,  after  one  of  the  methods 
already  advised.  The  fluid  ust-d  should  be  as  warm  as  the  patient 
can  bear  it,  and  may  be  slightly  medicated  in  the  later  stages  by 
the  addition  of  chloride  of  sodium,  tincture  of  iodine,  or  iodide  of 
potassium.  The  injections  stimulate  the  absorbents,  and,  at  the 
same  time,  quiet  inflammatory  action,  in  the  performance  of  which 
functions  the}^  are  invaluable  in  these  cases. 

As  the  third  stage  of  the  disease,  or  the  stage  of  sui>puration, 
merges  into  pelvic  abscess,  it  will  be  best  to  postpone  the  conside- 
ration of  its  management  to  the  chapter  in  which  that  subject  is 
treated.  I  will  merely  state  here  that  after  an  abscess  has  formed 
and  evacuated  itself,  great  care  should  be  taken  not  to  allow  the 
patient  to  exert  hei-self  for  several  weeks,  for  fear  of  a  relapse,  and 
even  after  she  has  left  the  house  and  begun  to  exercise  regularly, 
during  two  or  three  menstrual  periods  she  should  confine  herself 
to  bed. 


DEFINITIOIS'    AND    HISTORY.  465 


CHAPTER    XXVIII. 


PELVIC   PERITONITIS. 


Definition. — Inflammation  involving  the  peritoneum  covering  tlie 
female  pelvic  viscera,  and  limited  to  it,  receives  the  name  of  pelvic 
peritonitis.  It  must  not  be  supposed  that  bj  this  definition  is 
meant  simply  that  form  of  peritoneal  inflammation  arising  in  the 
pelvis  and  spreading  into  general  peritonitis,  which  has  long  been 
described  as  metro-peritonitis.  The  disease  that  we  are  now  con- 
sidering is  one  usually  strictly  limited  to  the  pelvis,  presenting 
symptoms  peculiar  to  itself,  and  rarely  passing  into  the  general 
form  of  the  same  disorder. 

History. — Long  before  pelvic  cellulitis  was  known,  peritonitis, 
limited  to  the  serous  covering  of  the  pelvic  organs,  had  attracted 
attention,  and  its  clinical  resemblance  to  cellulitis,  as  subsequently 
described,  fully  noted.  Thus  Morgagni*  relates  a  case  in  which, 
thirty  days  after  delivery,  the  right  ovary  and  tube  were  adherent 
to  the  colon  and  almost  destroyed  by  an  abscess.  Nauche,  in  his 
work  on  Diseases  of  the  Uterus,  published  at  Paris  in  1816, 
described  inflammation  of  the  uterus  as  affecting,  first,  the  mucous 
membrane,  second,  the  parenchyma,  and  third,  the  serous  cover- 
ing. In  1828,  Mad.  Boivin  credited  the  adhesions  resulting  from 
this  affection  and  binding  the  uterus  down,  with  a  large  number 
of  abortions  attributed  to  other  causes,  and,  in  1833,  she  described 
immobility  of  the  uterus,  for  which  she  gave  as  causes,  peritonitis, 
metro-peritonitis,  and  pelvic  abscess.  In  1839,  Grisolle^  distinctl}' 
stated,  that  "there  are  cases  of  circumscribed  peritonitis  which, 
producing  a  tumor  appreciable  to  sight  and  to  touch,  may  lead  to 
the  belief  in  the  existence  of  phlegmon,"  i.  ^.,  a  tumor  the  result 
of  inflammation  of  areolar  tissue.  Lisfranc,^^  writing  ten  years 
after  Boivin  and  Dug^s,  copies  their  description  very  closely  in  his 
article  on,  "  Fixity  de  la  Matrice,"  without  referring  to  them,  and 
like  them  attributes  it  to  peritonitis  or  metro-peritonitis. 

'  Artie.  22,  epist.  46.     Nonat,  op.  cit.,  p.  234. 
2  Bernutz  and  Goupil,  op.  cit.,  p.  398. 
^  Clin.  Med.,  vol.  iii,  p.  514. 

30 


466  PELVIC    PEKITONITIS. 

Although  these  facts  were  known  and  universally  admitted, 
they  attracted  little  notice,  and  after  the  description  of  pelvic 
cellulitis  hy  Doherty  and  Marchal  de  Calvi,  pelvic  peritonitis 
was  almost  entirely  lost  sight  of.  This  was  due  to  the  fact  that 
the  enthusiasm  created  by  the  description  of  a  long-forgotten 
affection,  caused  observers  to  look  upon  the  results  of  peritonitis 
as  those  of  cellulitis,  and  to  describe  them  as  such.  Thus  the 
matter  rested  until  1857,  when  M.  Bernutz,  in  a  treatise  written 
in  concert  with  M.  Goupil,  not  only  drew  especial  notice  to  it, 
but  took  the  position  that  inflammation  of  the  cellular  tissue  im- 
mediately around  the  uterus,  described  by  Konat  as  "  phlegmon 
periuterin,"  or  what  would  strictly  be  termed,  in  our  nomenclature, 
"periuterine  cellulitis,"  did  not  exist  as  a  pathological  reality, 
but  that  the  lesions  ascribed  to  it  were  absolutely  due  to  pelvic 
peritonitis. 

These  views,  published  at  first  in  the  "  Archiv.  G^n.  de  M^d.,"' 
are  fully  elaborated  in  the  admirable  work^  of  these  observers 
more  recently  brought  forth.  They  do  not  touch  the  general  sub- 
ject of  periuterine  cellulitis  as  it  exists  in  the  broad  ligaments, 
subperitoneal  tissue,  and  around  the  rectum,  but  only  tliat  variety 
supposed  to  have  its  seat  in  the  areolar  tissue  between  the  uterus 
and  peritoneum. 

It  has  been  already  stated  that  M.  Bernutz  was  incited  to  his 
investigations  by  certain  views  advanced  by  M.  Konat  as  to  the 
pathology  of  periuterine  induration,  which  sometimes  goes  on  to 
suppuration.  But  his  researches  served  not  merely  to  settle  this 
comparative!}^  unimportant  point,  they  proved  the  fact,  for  which 
the  investigator  appears  to  have  lieen  himself  entirely  unpre}»ared 
in  the  beginning,  that  many  of  those  cases  regarded  as  instances 
of  non-puerperal  cellulitis  are  in  reality  not  jthlegmonous  but 
peritoneal  inflammations.  Since  'the  publication  of  these  views 
I  have  directed  my  attention  particularly  to  this  point,  and  from 
careful  observation,  both  clinical  and  post-mortem,  feel  warranted 
in  recording  the  conclusions  at  which  I  have  arrived  in  the  follow- 
ing propositions : 

1st.  Periuterine  cellulitis  is  rare  in  the  non-pregnant  woman, 
while  pelvic  peritonitis  is  exceedingly  common  ; 

2d.  A  very  large  proportion  of  the  cases  now  regarded  as  in- 
stances of  cellulitis  are  really  those  of  pelvic  peritonitis  ; 

3d,  The  two  aflfections  are  entirely  distinct  from  each  other,  and 

'  Archiv.  Gen.,  18?T.  2  Clin.  M6d.  des  Femnies.  1862. 


HISTORY.  4(37 

should  not  be  confounded  simply  because  they  often  complicate  each 
other.  They  may  be  compared  to  serous  and  parenchymatous  in- 
flammation of  the  lungs — pleurisy  and  pneumonia.  Like  them 
they  are  separate  and  distinct,  like  them  afiect  different  kinds  of 
structure,  and  like  them  generally  complicate  each  other. 

4th.  They  may  usually  be  differentiated  from  each  other,  and 
a  neglect  of  the  effort  at  such  thorough  diagnosis  is  as  reprehensible 
as  a  similar  want  of  care  in  determining  between  pericarditis  and 
endocarditis. 

M.  Bernutz  cites  the  results  of  five  autopsies^  by  himself,  and 
between  twenty  and  thirty  by  others  which  presented  all  the  signs 
of  pelvic  peritonitis  and  none  of  cellulitis,  although  during  life 
the  symptoms  and  signs  generally  attributed  to  the  latter  disease 
were  present.  As  an  example  conveying  some  idea  of  the  close 
clinical  resemblance  between  his  cases  found  in  autopsy  to  be 
peritonitis  and  those  ordinarily  regarded  as  cellulitis,  I  quote  the 
salient  jjoints  in  his  sixth  observation. 

Patient  33,  lymphatic  temperament,  entei-ed  hospital  l^ovember 
24th  for  feebleness,  pain  in  the  back,  emaciation,  and  dysmenor- 
rhoea.  After  a  while  loss  of  appetite,  increase  of  pain,  and  chills 
appeared.  By  touch  the  uterus  was  found  completely  fixed,  low 
down  in  the  pelvis  and  inclined  to  the  right  side,  and  attached  to 
it  a  very  sensitive  tumor  the  size  of  a  hen's  egg^  extending  behind 
the  womb.  On  the  15th  of  December  this  tumor  was  as  large  as 
a  turkey's  egg.  February  1st :  tumor  only  the  size  of  a  pigeon's 
egg;  a  circumscribed  tumor  on  the  left  attached  to  uterus  and 
to  the  walls  of  the  pelvis.  March  23d:  uterus  movable  and 
tumor  reduced  to  the  size  of  a  little  nut.  April  4th :  she  died ; 
and  autopsy  showed  tubercular  pelvic  peritonitis,  evidenced  by 
tubercular  deposit,  lymph,  pus,  firm  old  adhesions,  ovaries  im- 
bedded in  false  membrane  and  nearly  destroyed. 

I  had  often  been  struck  by  the  great  similarity  between  peri- 
tonitis and  many  of  the  cases  of  what,  until  enlightened  by  M. 
Bernutz,  I  had  regarded  as  cellulitis,  and  hj  the  fact  that  they 
occasionally  ran  into  general  peritonitis  without  any  apparent 
emptying  of  purulent  collections  into  the  peritoneal  sac,  but  I 
never  had  an  opportunity  of  examining  such  a  case  post-mortem 
until  the  following  presented  itself: 

Mrs.  M.,  aged  35,  married,  but  never  pregnant,  was  under  my 

'  I  have  rejected  a  number  of  the  cases  reported,  because  not  suflBciently  conclu- 
sive. 


468  PELVIC    PEEITONITIS. 

care,  during  the  winter,  at  the  Woman's  Hospital,  for  anteflexion 
of  the  uterus,  the  result,  as  I  supposed,  of  periuterine  cellulitis. 
August  6th:  I  was  called  to  see  her  in  consultation  with  Dr.  Roth, 
her  family  physician,  and  found  her  suffering  from  severe  pelvic 
pain,  constant  vomiting,  and  fever.  Upon  vaginal  touch  I  found 
the  uterus  immovably  fixed  and  the  pelvic  roof  as  hard  as  a  board. 
The  pelvic  tissue  was  everywhere  hard  and  resisting,  and  the 
physical  signs  of  what  I  had  habitually  styled  cellulitis  were 
present.  About  a  week  afterwards  the  patient  died  suddenly  and 
unexpectedly,  and  I  made  an  autopsy  in  presence  of  Drs.  Roth  and 
J.  C.  Smith.  JS'o  general  peritonitis  existed;  the  left  ovary  pre- 
sented a  sac  the  size  of  a  hen's  egg,  filled  with  pus ;  the  pelvic 
peritoneum  was  intensely  inflamed  and  the  uterus  bound  down  by 
old  false  membranes,  bands  of  which  matted  all  the  parts  together. 
The  vermiform  a}>})endagc  was  bound  to  the  right  ovary  and  the 
caput  coli  lay  just  below  the  uterus.  No  trace  of  inflammation 
could  be  discovered  in  the  yielvic  cellular  tissue  except,  of  course, 
that  in  inmiediate  contact  with  the  ovary. 

The  fixation  of  the  uterus,  observed  during  life,  was  due  to 
lymph  eftused  u[ion  the  jjclvic  j^eritoneum,  and  no  trace  of  inflam- 
matory action  in  the  pelvic  areolar  tissue  could  be  discovered  as 
accounting  for  it.  It  is  true  that  the  left  ovary,  enveloped  by 
the  layers  of  the  broad  ligament,  was  inflamed,  and  that  a  certain 
amount  of  inflammation  existed  in  the  cellular  tissue  inmiediately 
surrounding  it,  but  this  did  not  extend. 

Frcqueitcy. — A  reference  to  the  autopsic  notes  of  cases  of  cellulitis, 
for  example  those  recorded  by  AVest,  Nomit,  Aran,  and  McClintock, 
will  give  abundant  evidence  of  the  almost  universal  attendance  of 
this  complication  upon  it.  But,  even  without  the  existence  of  that 
disease,  Aran  found  it  in  greater  or  less  degree  in  fifty-five  per  cent, 
of  cadavers  of  women  examined  in  his  service.  This  proves  that 
peritonitis,  limited  to  the  pelvic  viscera,  is  a  common  affection, 
and  one  which  is  very  generally  overlooked.  It  is  probably  to  its 
occurrence  that  are  due  so  many  of  those  attacks  of  violent  hypo- 
gastric pain  occurring  with  menstruation,  or  just  after  it,  accom- 
panied by  vomiting  and  slight  febrile  action,  and  which  are  gene- 
rally treated  by  domestic  remedies  and  viewed  as  cramps  or  uterine 
colic. 

Pathology. — The  disease  runs  its  course  here,  as  peritoneal  inflam- 
mation does  elsewhere,  in  three  stages.  In  the  first  there  are 
simple  engorgement  and  turgescence  of  the  vessels,  producing  red- 


PATHOLOGY.  469 

ness,  dryness,  and  pain.  In  the  second  stage  an  entirely  different 
state  of  things  will  be  found  to  exist,  to  comprehend  which  fully, 
the  reader  must  bear  in  mind  what  is  meant  by  the  "roof  of  the 
pelvis."  If  a  plane  be  passed  backwards  from  a  point  just  under 
the  pubic  arch,  through  the  cervix  uteri  at  the  attachment  of  the 
vagina,  to  the  sacrum  at  the  attachment  of  the  utero-sacral  liga- 

Fig.  140. 


The  straight  line  represents  approximately  the  roof  of  the  pelvis  ; 
the  dotted  line  represents  it  more  exactly. 

ments,  it  will  correctly  represent  this  roof,  which  is  thus  formed 
by  the  vesico-vaginal  septum,  the  lower  extremity  of  the  uterus, 
which  projects,  as  it  were,  through  a  hole  in  the  roof,  the  upper 
part  of  the  fornix  vaginae,  and  the  utero-sacral  ligaments.  Above 
the  plane,  the  organs  of  reproduction  float,  as  !Nonat  expresses  it, 
"in  an  atmosphere  of  cellular  tissue."  Let  the  reader  suppose  that 
instead  of  this  j'ielding,  sf)ringy  tissue,  these  organs  were  fixed  in 
their  places  by  having  a  fluid  mixture  of  plaster  of  Paris  poured 
around,  among,  and  over  them,  which  had  afterwards  become  solid, 
and  he  may  form  a  correct  idea  of  what  vaginal  exploration  will 
yield  to  the  sense  of  touch  in  the  second  stage.  The  roof  of  the 
pelvis  is  hard,  ligneous,  and  as  if  composed  of  a  "deal  board,"  to 
which  Prof.  Doherty  likens  it.  The  uterus,  which  is  generally 
much  displaced,  is  immovable,  and  all  its  appendages  appear  fixed 
by  some  solid,  surrounding  element. 

This,  the  second,  stage  consists  in  a  collection  of  plastic  lymph 
on  the  surface  of  the  peritoneum,  and  of  serous,  purulent,  or  sero- 
purulent  fluid  in  its  most  dependent  parts. 


470  PELVIC    PERITONITIS. 

In  the  tliird  stage  the  fluid,  if  serous,  is  absorbed ;  if  purulent, 
discharged,  and  the  ^exuded  lymph  undergoes  organization  and 
subsequently  contraction.  This  binds  the  uterus,  its  appendages, 
and  some  of  the  intestines  together  in  a  mass,  which  yields  all  the 
physical  signs  of  a  tumor. 

Causes. — Its  causes  are  the  following: 

Periuterine  cellulitis ; 
Parturition  or  abortion; 
Gonorrhoea ; 

Endometritis,  ovaritis,  or  salpingitis ; 
Escape  of  fluids  into  the  peritoneum ; 
Traumatic  influences ; 
Imprudence  during  menstruation; 
Tuberculous  or  cancerous  deposit ; 
Uterine  displacement. 

Its  frequent  dependence  on  the  first  needs  no  further  mention. 

As  a  result  of  parturition  or  abortion,  it  is  so  well  known  as  to 
make  the  exhibition  of  proof  here  almost  unnecessary.  Reference 
may  be  made,  however,  to  53  autopsies  by  Aran,*  in  which  out  of 
38  women  who  had  borne  children,  24  presented  evidences  of  its 
previous  existence,  while  out  of  15  who  were  uuUiparous,  only  5 
did  so. 

Gonorrhoea,  by  passing  into  the  uterus  and  through  the  Fallo- 
pian tubes,  is  a  fruitful  source  of  the  affection.  According  to  M. 
Bernutz,  28  out  of  99  of  his  cases  had  this  origin.  I  have  seen 
a  number  of  severe  cases  due  to  it,  and  the  great  importance  at- 
tached to  this  cause  by  Noeggerath  is  elsewhere  fully  stated. 

It  would  be  strange  if  ovaritis  and  endometritis  did  not,  at  times, 
cause  pelvic  peritonitis.  That  they  frequently  do  so,  is  abundantly 
demonstrated  by  autopsies  made  after  their  existence  both  in  the 
puerperal  and  non-puerperal  states. 

Salpingitis  causes  it  not  only  by  the  extension  of  inflammation 
along  the  mucous,  into  the  serous  membrane  Avhich  is  continuous 
with  it,  but  by  emptying  its  accumulated  pus  into  the  peritoneal 
cavity. 

Escape  of  fluid  into  the  peritoneum  is  an  undisputed  cause  of 
this,  as  of  general  peritonitis.  I  myself  produced  a  well-marked 
case  which  almost  terminated  fatally,  by  injecting  a  solution  of 
persulphate  of  iron  into  the  uterine  cavity.     The  passage  of  the 

'  Op.  cit.,  718. 


CAUSES.  471 

fluid  through  the  tubes  could  not  be  questioned,  for  agonizing 
pain  came  on  in  less  than  three  minutes,  and  continued  up  to  the 
development  of  inflammation.  This  danger  has  caused  the  almost 
entire  abandonment  of  intra-uterine  injections  on  tlie  part  of  the 
majority  of  practitioners,  unless  the  cervix  be  previously  dilated 
l)y  tents.  But  many  other  sources  from  which  fluid  may  ente'r 
the  peritoneum  exist ;  as,  for  example,  rupture  of  an  ovarian  cyst, 
discharge  of  tubal  dropsy,  or  of  a  pelvic  abscess,  intra-peritoneal 
hemorrhage,  regurgitation  of  obstructed  menstrual  blood,  etc. 

Traumatic  agencies,  as  blows,  falls,  injury  during  labor,  punc- 
tures, etc.,  may  result  in  partial,  as  they  do  in  general  inflamma- 
tion of  the  peritoneum. 

During  the  performance  of  menstruation,  a  physiological  func- 
tion which  involves  ovarian  rupture  and  produces  hemorrhage, 
which  must  pass  to  the  uterus  by  a  narrow  tube  not  permanently 
in  immediate  contact  with  the  ovary,  any  degree  of  exposure  must 
evidently  tend  to  inflammation  in  the  investing  peritoneum.  Of 
M.  Bernutz's  99  cases,  20  were  thus  produced. 

Tubercles  deposited  in  the  part,  either  on  the  peritoneum  or  in 
the  tissue  of  the  tubes  or  uterus,  may,  as  they  do  elsewhere,  result 
in  secondary  inflammation ;  and  cancerous  or  cancroid  degeneration 
would  be  still  more  likely  to  produce  the  same  result. 

In  certain  peculiar  states  of  the  system  this  affection  is  ex- 
cited by  the  most  trivial  circumstances,  and  very  commonly  the 
physician  is  held  to  a  severe  account  for  the  fatal  issue  of  an  affec- 
tion which  he  as  little  expected  to  arise  from  his  interference  as  the 
friends  of  the  patient  did.  I  have  seen  it  excited  b}^  the  passage 
of  the  uterine  sound,  the  use  of  a  small  sponge  tent,  and,  in  one 
case,  from  the  passage  of  water,  used  by  vaginal  injection,  into  the 
uterus.  Dr.  Barnes,  in  his  late  excellent  work  on  the  "  Diseases  of 
Women,"  says,  "  I  have  seen  fatal  peritonitis  follow  the  simple 
application  of  nitrate  of  silver  to  the  cervix  uteri."  It  should  be 
the  duty  of  every  physician  to  shield  an  unfortunate  brother  prac- 
titioner by  the  protection  which  these  facts  legitimately  atford  him ; 
but  it  should  equally  be  the  duty  of  each  to  remember  -this  para- 
graph, the  whole  of  which  is  italicized  in  Dr.  Savage's  work  upon 
the  Female  Sexual  Organs — "  No  surgical  proceeding  whatever, 
touching  any  part  of  the  uterine  system,  should  be  unattended  by 
the  precautions  observed  in  operations  of  a  grave  character  there 
or  elsewhere ;  in  certain  states  of  the  general  system  unforeshadowed 
by  any  recognizable  peculiarity,  the  most  trivial  operation  has  been 
speedily  followed  by  fatal  peritonitis." 


472  PELVIC    PERITONITIS. 

Varieties. — This  affection  may  assume  either  an  acute  or  chronic 
form,  though  when  it  constitutes  the  principal  disease  it  generally, 
in  the  beginning,  presents  the  features  of  the  former.  When  it 
occurs  as  a  complication  of  tuberculosis  or  uterine  disease,  it  often 
assumes  from  the  beginning  the  chronic  type.  Besides  these 
varieties  there  are  two  others  which  cannot  be  passed  without 
notice — menstrual  pelvic  peritonitis  which  becomes  aggravated  at 
periods  of  ovulation,  and  recurrent  peritonitis  which  lasts  for  many 
years,  giving,  however,  immunity  for  long  periods,  and  then  recur- 
ring with  great  violence  from  a  trivial  cause.  I  have  now  under 
my  care  two  such  cases,  one  of  which  has  lasted  ten  and  the  other 
eight  years.  For  eight,  ten,  or  twelve  months  these  patients  enjoy 
an  almost  absolute  immunity  from  the  disorder :  then,  excited  by 
some  apparently  insignificant  cause,  a  severe  and  excessively  pain- 
ful attack  comes  on.  One  of  these  cases  is  always  complicated  by 
cellulitis,  and  a  purulent  accumulation  frequently  discharges  itself 
through  the  pelvis  as  a  consequence  of  these  attacks. 

Symptoms. — The  acute  form  shows  itself  by — 

Pelvic  pain  and  tenderness ; 

Sometimes  great  vesical  irritation  ; 

Fever ; 

Usually  increased  thermometric  range  ; 

Nausea  and  vomiting ; 

Anxious  facies ; 

Mental  disturbance ; 

Tympanites. 

When  a  severe  acute  attack  sets  in,  it  may  cause  either  a  chill, 
or  a  sensation  of  coldness  so  slight  that  the  patient  will  not  recall 
its  occurrence  unless  her  attention  be  especially  directed  to  it ;  or 
pain  and  fever  may  show  themselves  without  this  symptom. 

Pain  is  at  times  only  moderate,  but  at  others  most  severe.  It 
may  occur  in  paroxysms,  which  create  the  greatest  agony  and 
prostrate  the  patient  by  their  severity.  I  have  seen  it  amount 
to  agony  equal  to  that  arising  from  the  passage  of  a  biliary  cal- 
culus, causing  the  patient  to  roll  in  bed,  seize  the  bedclothes  in 
the  teeth,  and  cry  aloud  most  piteously.  As  a  rule,  it  is  not  so 
violent  as  this.  Pain  may  show  itself  quite  early  in  the  disease, 
or  may  be  preceded  for  several  days  by  pelvic  uneasiness  and 
weight. 

Tenderness  over  the  whole  hypogastrium  accompanies  it  to  such 


SYMPTOMS.  473 

a  degree,  that  even  the  weight  of  the  bedclothes  is  intolerable, 
and  the  patient,  to  relieve  it,  lies  upon  the  back  with  the  legs 
flexed  in  order  to  relax  tlie  abdominal  muscles. 

The  pulse  shows  in  slight  cases  very  little,  and  in  severe  cases 
a  considerable  amount  of  febrile  action.  It  is  small  and  wiry, 
and  increases  in  rapidity  to  110  or  120  to  the  minute. 

The  thermometric  range  is  likewise  variable.  In  the  beginning 
of  an  attack,  which  may  become  a  severe  one,  the  range  may  be 
normal,  or  even  below  the  normal  standard.  "  Sub-normal  tem- 
peratures are  especially  common  in  peritonitis,"  says  Wunderlich, 
"  and  always  suspicious ;  death  may  follow  them  closely.  High 
and  rising  temperatures  do  not  add,  per  sf,  arguments  for  an  un- 
favorable termination,  althouo-h  adding;  another  danoerous  element 
to  the  case.  It  is  not  so  much  the  actual  height,  as  its  constancy, 
which  must  be  feared  ;  as  are,  also,  great  and  irregular  fluctuations 
between  very  high  and  very  low  temperatures."  When,  however, 
a  case  commences  with  a  temperature  of  106°,  it  is  greatlj^  to  be 
feared  that  it  will  run  a  violent  and  dangerous  course.  On  the 
other  hand,  even  a  normal  temperature  should  not  give  complete 
security,  although  a  decidedly  favorable  augury  may  usually 
be  drawn  from  it.  In  general  terms  it  may  be  said  that  for  him 
who  implicitly  trusts  to  the  revelations  of  the  thermometer  in 
this  aflection,  it  will  prove  an  unreliable  guide ;  but  to  him  who 
looks  upon  them  merely  as  aids  to  diagnosis  and  prognosis,  it  will 
give  decided  assistance. 

Nausea  and  vomiting  are  common  symptoms,  though  they  do 
not  generally  exist  to  such  a  degree  as  to  prove  very  annoying. 

The  facies  is  peculiarly  anxious,  and  is  sometimes  rendered  very 
striking  by  the  appearance  of  dark  circles  around  the  eyes. 

I  have  generally  noticed  in  acute  cases  that  the  mind  is  mark- 
edly disturbed,  as  if  the  patient  instinctively  dreaded  some  serious 
disease,  and  even  in  chronic  cases  there  is  a  decided  tendency  to 
slight  mental  alienation.  In  several  cases  I  have  seen  this  advance 
to  absolute  insanity. 

It  may  justly  be  observed  that  these  are  the  symptoms  which 
mark  general  peritonitis.  This  is  true ;  it  is  merely  the  slighter 
degree  of  severity  and  the  localization  of  pain  and  tenderness, 
which  will  point  to  the  partial  nature  of  the  afltection. 

With  reference  to  general  peritonitis,  it  may  be  stated  that,  on 
the  one  hand,  it,  of  all  diseases,  may  declare  itself  by  the  most 
numerous  and  characteristic    symptoms,  or,  on  the  other,  run  its 


47-4  PELVIC    PERITONITIS. 

fearful  course  with  the  greatest  ohscurity,  so  as  to  mislead  the 
most  careful  diaguostician,  eveu  up  to  its  latest  stages.  If  this  be 
true  as  to  the  general  disorder,  how  much  more  must  it  be  so  as 
to  the  local.  Thus  it  is  that  we  find  the  subacute  and  chronic 
forms  passing  off  without  recognition,  and  the  fact  that  they  have 
existed  is  known  only  by  the  discovery  of  firm  adhesions  over 
the  whole  pelvic  roof  in  post-mortem  examinations.  In  these 
varieties,  there  is  less  pain  and  tenderness  and  less  tendency  to 
nausea  and  febrile  action  than  in  the  acute.  Sometimes,  indeed, 
there  is  merely  a  sense  of  local  discomfort,  increasing  to  pain  at 
menstrual  periods,  accompanied  by  fever  towards  evening,  by 
difficulty  in  locomotion,  alid  by  a  general  sense  of  feebleness  and 
malaise.  This  remarkable  absence  of  symptoms  in  pelvic  perito- 
nitis was  announced  by  Aran,  and  Dr.  Duncan^  exj^resses  himself 
upon  it  in  these  words :  "■  I  might  adduce  cases  of  gonorrhoeal 
ovaritis  commencing  in  healthy  young  girls,  and  ending  in  the 
fusion  of  all  the  parts  in  the  pelvis  into  a  solid  immovable  mass, 
without  the  patient  losing  a  cheerful,  and  even  gay  visage,  or 
making  any  great  complaint  of  pain,  unless  interrogated  closely, 
and  then  alleging  the  chief  sufiering  to  be  from  irritable  bladder." 

Physical  Signs. — Should  an  examination  be  made  during  the 
first  stage,  nothing  will  be  ascertained  but  the  existence  of  sensi- 
tiveness upon  pressure  in  the  vaginal  cul-de-sac  and  upon  lifting 
the  uterus.  Tenderness  will  likewise  be  demonstrated  by  pres- 
sure on  the  hypogastrium.  Isone  of  that  doughy,  oedematous, 
pufly  feel  which  accompanies  cellulitis  will  be  discovered  by 
vaginal  touch.  Should  the  disease  run  its  course  as  one  of  those 
very  insignificant  attacks,  which  i)roduce  no  grave  symptoms  and 
are  scarcely  recognizable,  no  other  physical  signs  will  present 
themselves  at  this  or  any  other  period.  Should  it  be  one  of  graver 
character,  a  sense  of  resistance  merely,  or  a  tumefaction  like  an 
ill-defined  tumor,  may  be  felt  in  the  recto-vaginal  space  or  at  the 
side  of  the  uterus.  Or  if  very  little  lymph  and  much  sero-pus 
have  been  the  result  of  the  inflammatory  action,  a  sense  of  fluctu- 
ation may  be  detected  very  early.  The  uterus  is  always  more  or 
less  interfered  with  in  its  mobility,  and  in  severe  cases  it  is  abso- 
lutely fixed.  This  explains  how  Lisfranc  and  Boivin  applied  to 
it  the  name  of  "  fixity"  or  "  immobility"  of  the  uterus. 

I  have  stated  that  a  tumor  is  commonly  felt  posterior  to,  or  at 
one  side  of  the  uterus.     This  tumor,  which  is  formed  by  agghiti- 

'  "  Perimetritis  and  Parametritis,"  p.  78. 


COUESE,    DUEATION,    AND    TERMINATION".  475 

nation  of  tlie  pelvic  and  abdominal  viscera,  is  extremely  sensitive 
to  touch. 

If  the  disease  go  on  to  formation  of  pus,  the  sense  of  tumefaction 
may  disappear  as  this  discharges  itself,  but  if  the  eftused  lymph 
become  thoroughly  organized,  it  remains  hard  and  resisting  for  a 
length  of  time.  This  accumulation  almost  invariably  displaces  the 
uterus,  sometimes  by  pressing  it  in  an  opposite  direction,  sometimes 
by  drawing  it  towards  itself  as  the  lymph  contracts. 

In  a  case  which  I  saw  some  years  ago  with  the  late  Prof.  G.  T. 
Elliot,  we  were  much  puzzled  for  a  short  time  before  its  fatal  issue, 
by  the  existence  in  the  fornix  vaginse  of  a  pouch,  apparently  filled 
with  fluid,  all  the  surrounding  parts  being  unattached  and  no  sense 
of  tumefaction  or  resistance  being  discoverable.  The  patient  died 
suddenly  from  general  peritonitis,  and  upon  post-mortem  examina- 
tion, conducted  by  Prof.  J.  W.  S.  Gouley,  we  found,  first,  a  small 
piece  of  fetid  placenta  in  utero,  the  result  of  a  recent  abortion; 
second,  an  abscess  of  the  right  ovary,  which  had  created  general 
peritonitis  by  emptying  itself  into  the  peritoneum ;  and  third, 
pelvic  peritonitis,  which  had  evidently  existed  for  more  than  a 
week.  It  had  created  a  purulent  collection  in  Douglas's  cul-de-sac, 
which  was  limited  to  this  space  by  false  membranes,  that  formed 
for  it  a  complete  roof.  This  accumulation,  it  was,  which  gave  the 
sensation  above  described. 

In  another  case,  sent  to  me  by  Prof.  J.  C.  Hutchinson,  of  Brook- 
lyn, the  uterus  was  found  firmly  bound  to  the  sacrum  by  a  hard, 
resisting  mass,  which  was  very  sensitive.  There  was  considerable 
corporeal  endometritis,  and  I  incautiously  applied  to  the  uterine 
cavity  tincture  of  iodine,  and  as  a  result  the  most  violent  pelvic 
peritonitis  developed  itself,  which  almost  became  general.  In  ten 
days  after  its  inception,  a  soft,  fluctuating  pouch  formed  in  the 
fornix  vaginae,  which  became  so  painful  that  I  tapped  it  with  an 
exploring  needle  and  drew  oft"  about  an  ounce  of  clear  serum, 
much  to  the  patient's  relief. 

Course^  Duration^  and  Termination. — In  no  disease  can  these  be 
more  variable  and  uncertain  than  in  that  under  consideration.  A 
great  similarity  exists  between  its  phases  and  those  of  pleuritis. 
As  in  that  aftection  we  have  shades  of  difterence,  varying  from 
the  ordinary  "stitch  in  the  side,"  which  results  from  inflammation 
of  a  portion  of  the  pleura  not  larger  perhaps  than  a  silver  half 
dollar,  to  empyema  and  tubercular  pleuritis,  which  may  continue 
till  death  by  pulmonary  consumption  or  pneumothorax  closes  the 
scene,  so  may  we  have  in  pelvic  peritonitis  like  variations.     It 


476  PELVIC    PERITONITIS. 

may  run  its  course  unobserved,  leaving  evidence  of  its  existence 
only  in  adhesions  found  post  mortem.  It  may  pass  through  its 
first  two  stages  in  three  or  four  weeks,  leaving  the  uterus  perma- 
nently displaced  by  the  continuance  of  the  third.  It  may  reap- 
pear with  a  certain  amount  of  acuteness  at  menstrual  periods, 
causing  them  to  be  very  painful.  It  may,  if  due  to  tul:)ercular 
deposit,  continue  so  as  to  exhaust  the  patient  slowly.  It  may 
produce  a  purulent  collection,  which,  by  emptying  itself  into  the 
peritoneum  through  the  adhesions  thrown  around  it,  may  create 
general  peritonitis,  or  this  last  may  result  from  the  spread  of 
morbid  action  from  the  pelvic  to  the  general  serous  membrane. 

Differentiation. — The  diseases  with  which  this  is  most  likely  to 
be  confounded  are — 

Periuterine  cellulitis ; 
Pelvic  hematocele; 
Fibrous  tumors ; 
Fecal  impaction. 

Periuterine  Cellulitis. — Diiferentiation  between  these  two  affec- 
tions is  in  some  cases  simple  enough,  but  in  others  it  is  impossible. 
Difiiculty  will  occur  when  cellulitis  affects,  and  is  confined  to,  the 
tissue  most  immediate  to  the  uterus,  but  this  we  know  to  be  very 
rare.  Our  suspicions  will  often  be  turned  into  the  proper  channel 
by  the  cause  of  the  attack.  Cellulitis  will  very  rarely  occur  except 
after  parturition,  abortion,  or  an  operation  on  the  pelvic  viscera. 
Peritonitis  will  usually  result  from  exposure  during  menstruation, 
disease  of  the  ovaries,  or  escape  of  fluid  into  the  peritoneum. 
Should  the  attack  occur  as  a  result  of  gonorrhoea,  it  is  probably 
due  to  serous  and  not  cellular  inflammation,  a  fact  which  the 
anatomical  relations  would  lead  us  a  priori  to  anticipate,  and 
which  is  fully  substantiated  by  statistics.  West  and  Aran  credit 
gonorrhoea  with  the  causation  of  cellulitis  in  from  one  to  two  cases 
in  a  hundred,  and  Bernutz  declares  it  active  in  twenty-eight  out 
of  a  hundred  of  peritonitis. 

Pelvic  Hematocele. — From  this  it  may  be  distinguished  by  the 
great  suddenness  of  appearance  of  hematocele,  absence  of  signs  of 
inflammation  in  the  beginning,  presence  of  those  of  hemorrhage, 
and  by  the  much  greater  dimensions  of  the  tumor,  which,  unlike 
that  of  peritonitis,  is  at  first  rather  soft  and  gradually  becomes 
hard.  The  occurrence  of  free  bloody  flow  will  likewise  point  to 
hematocele,  though  such  an  occurrence,  to  a  limited  extent,  often 


PEOGNOSIS.  477 

takes  place  in  peritonitis.     Hematocele  often  excites  peritonitis, 
and  thus  both  frequently  exist  together. 

Fibrous  Tumors. — These  will  generally  be  known  by  their  pro- 
ducing no  pain,  presenting  no  sensitiveness  on  jiressure,  no  sense 
of  oedema,  no  signs  of  inflammation  nor  rapidity  of  development. 
They  are  likewise  usually  movable,  and  cause  no  fixation  of  the 
uterus. 

Fecal  Impaction. — After  pelvic  peritonitis  and  cellulitis  have  ex- 
isted for  some  time,  and  have  lost  their  features  of  acuteness,  and 
more  especially  after  opium  has  been  long  used  to  allay  the  pain 
which  attends  them,  tliey  are  very  apt  to  be  complicated  by  fecal 
impaction.  Not  only  is  this  a  complication,  I  have  known  it  exist 
long  after  the  inflammatory  aft'ection  which  preceded  it  has  passed 
away,  and  give  rise  to  the  belief  that  this  still  continues,  the  pain 
which  it  creates  being  attributed  to  the  primary  condition.  I  am 
now  prei)aring  for  publication  the  notes  of  four  very  striking  cases 
in  which  after  four  or  five  months  of  intense  suflering  from  sup- 
posed periuterine  inflammation,  which  was  treated  by  free  use  of 
opium,  I  discovered  great  fecal  impaction,  the  removal  of  which 
aftbrded  complete  and  permanent  relief.  So  frequent  do  I  consider 
the  development  of  this  condition  as  a  result  and  complication  of 
periuterine  inflammation,  or  as  an  independent  state  which  is  mis- 
taken for  it,  that  I  never  take  charge  of  a  case  which  has  been 
under  the  previous  treatment  of  others  without  examining  for  its 
existence,  and  in  the  management  of  cases  from  the  commencement 
under  my  charge,  always  carefully  guard  against  its  occurrence. 

Importance  of  differentiating  Peritonitis  from  Cellulitis. — The  im- 
portance of  differentiating  this  disease  from  cellulitis  rests  in  part 
upon  the  fact  that  it  admits  of  less  local  interference.  Sometimes 
the  passage  of  a  uterine  sound,  an  application  to  the  cavity,  or 
even  the  use  of  a  vaginal  injection  which  by  accident  has  entered 
the  uterus,  have  been  known  to  destroy  life  by  causing  peritonitis 
which  has  extended  to  the  whole  peritoneum.  It  is  likewise  import- 
ant in  reference  to  prognosis  as  to  the  course  of  the  affection  and  its 
remote  results.  Lastly,  it  should  not  be  forgotten  that  progress  in 
the  comprehension  of  the  diseases  of  all  organs  must  be  preceded 
by  a  careful  and  systematic  separation  of  them,  one  from  the  other. 
As  the  study  of  acute  cardiac  affections  under  the  common  name 
of  carditis  could  never  have  accomplished  what  that  of  each  of  its 
varieties  has  done,  so  could  not  investigation  of  these  affections, 
undivided  into  their  proper  classes. 

Prognosis. — If  the  case  follow  parturition  or  abortion,  the  prog- 


478  PELVIC    PEEITONITIS. 

nosis  will  be  rendered  graver  by  that  fact.  Otherwise  it  will  be 
governed  in  great  degree  by  the  general  symptoms.  Should  these 
show  great  intensity  of  inflammation,  and  constitutional  disturbance 
be  evidenced  by  excessive  nausea  and  vomiting,  quick  pulse,  anxious 
facies,  etc.,  in  other  M^ords,  should  the  symptoms  point  to  the  prob- 
able spread  of  the  disease  over  the  whole  serous  sac,  the  ordinary- 
prognosis  of  peritonitis  may  be  made.  In  cases  of  chronic  type, 
occurring  in  the  non-puerperal  state,  it  is  decidedly  fjivorable, 
unless  the  disease  exist  in  a  scrofulous  or  tuberculous  patient,  or 
show  a  tendency  to  severe  periodical  relapses.  Another  fact,  which 
will  increase  the  gravity  of  prognosis,  is  the  existence  of  purulent 
eifusion  in  place  of  lymph  and  serum  as  the  result  of  the  inflam- 
matory action. 

Results. — The  common  results  of  the  disease,  which  remain  long 
after  it  has  passed  away,  or  perhaps  permanentl}^  are  injury  of  the 
ovaries  by  abscess  or  atrophy;  obliteration  or  dropsy  of  the  tubes 
of  Fallopius;  and  fixation  of  the  womb  in  malposition,  by  organi- 
zation of  false  membranes.  As  consequences  of  these  lesions  follow 
very  naturally,  amenorrhoea,  dysmenorrhcea,  and  sterility. 

Treatment. — Should  the  medical  attendant  be  called  in  the  first 
stages,  leeches,  if  the  patient  be  strong,  should  be  applied  over  the 
hypogastrium,  and  a  poultice,  as  warm  as  can  be  borne,  sliould 
follow  them  immediately.  The  patient  should  be  brought  fully 
under  the  influence  of  opium  by  mouth,  rectum,  or  the  hypodermic 
syringe,  and  perfect  rest  should  be  enjoined.  No  cathartic  medicine 
should  be  given,  as  it  interferes  with  quietude,  and  it  is  well  to 
keep  the  bladder  empty  by  the  catheter.  Milk,  beef-tea,  and  other 
plain,  nutritious,  and  unstimulating  food  should  be  prescribed. 

The  sovereign  remedy  for  this  aflfection  is  opium,  not  in  small, 
but  in  large  and  repeated  doses,  carried  to  the  point  of  producing 
the  quietude  wlnich  is  necessary  for  the  favorable  jtrogrcss  of  the 
case.  Sometimes  this  condition  will  be  produced  by  one  grain  of 
opium,  in  powder,  or  quarter  of  a  grain  of  sulphate  of  morphia 
every  two  or  three  hours,  but  in  many  cases  half  a  grain  of  sulphate 
of  morphia  will  be  repeated  every  two  or  three  hours  for  a  long 
time  before  perfect  ease  is  obtained.  The  inexperienced  employer 
of  this  drug  in  these  doses  will  fear  dangerous  narcotism,  but  in 
New  York,  under  the  tuition  of  Alonzo  Clark,  to  whom  we  are  in- 
debted for  this  practice,  we  employ  it  with  the  greatest  confidence. 
Let  the  physician  avoid  all  other  drugs  and  give  opium  thus  freely 
in  one  or  two  cases  of  this  afiection,  and  he  will  appreciate  its  value. 

In  the  second  and  third  stages,  where  lymph  has  been  the  chief 


TREATMENT.  479 

and  perliaps  the  only  product  of  inflammation,  we  must  rely  upon 
counter-irritants,  and  I  know  of  none  to  be  compared  with  the 
blister.  One  made  of  Spanish  flies,  four  by  six  inches  in  dimen- 
sions, should  be  applied  over  the  hypogastrium  and  the  abrasion 
which  it  produces  dressed  with  savine  ointment.  As  soon  as  it 
heals  entirely,  another  should  be  applied  directly  over  the  newly- 
formed  skin,  and  this  may  be  repeated  every  ten  or  fourteen  days 
with  great  advantage.  I  have  known  patients  who  dreaded  them 
in  the  beginning  beg  for  them  after  experiencing  the  relief  which 
they  gave.  Should  the  patient  be  rendered  so  nervous  by  this 
remedy  that  it  cannot  be  employed,  or  should  any  other  reason 
prevent  its  use,  superficial  nitric  acid  issues  may  be  applied  over 
the  iliac  regions  and  kept  open  by  issue  peas  or  occasional  cauteri- 
zation with  solid  nitrate  of  silver.  The  blister  is  to  pelvic  peri- 
tonitis in  these  stages  what  it  is  to  pleuritis,  the  most  rapid  and 
efficient  of  remedial  agencies. 

Another  very  excellent  method  for  producing  counter-irritation 
is  by  tincture  of  iodine  painted  over  the  hypogastrium  once  in 
twenty-four  hours  for  weeks. 

Treatment  of  Chronic  Cases. — The  affection  having  passed  into 
the  chronic  stage,  or  originated  with  all  the  appearances  of  chronic 
disease,  a  different  course  of  management  becomes  advisable.  The 
patient  should  not  be  so  strictly  confined  to  bed  nor  dieted.  She 
has  entered  upon  an  invalid  course  which  may  last  for  months  or 
for  years,  and  in  making  a  strenuous  effort  to  cure  her  local  dis- 
order we  may  sap  her  general  health  and  do  her  irretrievable 
injury.  On  the  other  hand,  she  should  not  attend  to  her  house- 
hold cares,  nor  take  exercise  to  any  great  degree ;  but  remaining 
in  bed  or  on  a  lounge  most  of  the  time,  go  out  in  the  fresh  air  for 
an  hour  or  two  daily.  Her  diet  should  be  of  the  most  nutritious 
character,  stimulants  should  be  allowed  in  moderation,  and  the 
impoverished  blood  resulting  from  a  combination  of  circumstances 
prejudicial  to  hematosis,  combated  by  change  of  air  and  the  use 
of  vegetable  and  mineral  tonics,  especially  iron. 

One  of  the  most  important  questions  in  the  management  of 
chronic  cases  is  that  of  the  amount  of  exercise  to  be  allowed,  and 
the  strictness  of  confinement  to  be  practised.  Xo  absolute  rule 
can  be  laid  down  in  reference  to  these  points,  for  each  case  will 
call  for  special  guidance,  based  upon  careful  expei'iment.  In 
general  terms  it  may  be  stated  that  when  motion  does  not  produce 
pain  or  discomfort,  the  patient  should  ride  in  an  easy  carriage  for 
two  or  three  hours  daily.     In  those  cases  which  are  still  more  free 


480  PELVIC    PEKITONITIS, 

from  local  trouble,  she  may  walk  with  moderation ;  while  in  others 
which  present  elements  of  acuteness,  no  motion  whatever  should  he 
allowed.  Sometimes  the  patient  will  even  hear  removal  from  home 
to  the  sea-side  or  some  watering-place  during  the  summer.  If 
this  be  so,  a  locality  should  be  chosen  that  is  accessible  by  easy 
travel.  One  great  and  ever  recurring  difficulty  in  this  connection 
arises  from  the  great  tendency  of  patients,  allowed  to  take  exercise, 
to  commit  indiscretions  by  overtaxing  themselves.  This  becomes 
so  great  at  times,  as  to  make  it  advisable  to  confine  to  bed  one 
who  would  be  benefited  by  moderate  exercise,  in  order  to  avoid 
danger  from  her  imprudence.  The  fact  should  never  be  lost  sight 
of  that  the  pelvic  peritoneum  forms  a  part,  a  sheath,  as  it  were,  of 
the  suspensory  ligaments  of  the  uterus.  The  fibrous  structure  of 
the  round,  broad,  sacral,  and  vesical  ligaments  is  covered  by  it,  so 
that  dragging  of  the  uterus  upon  them  puts  the  jieritoneum  upon 
the  stretch  and  strongly  tends  to  excite  renewed  action  there. 

Of  all  influences  which  act  in  a  directly  prejudicial  manner  upon 
these  cases,  sexual  intercourse  is  the  most  decided,  and  its  strict 
limitation  should  be  made  one  of  the  first  rules  laid  down  for  their 
management. 

Should  acute  exacerbations  occur  in  chronic  cases,  the  use  of 
local  depletion  would  be  indicated,  but,  as  a  plan  to  be  strictly 
pursued  with  reference  to  cure,  it  is  highly  objectionable  on  account 
of  the  spannemia  which  it  induces. 

If  it  be  deemed  advisable  to  keep  up  the  use  of  the  iodide  or 
bromide  of  potassium,  the  results  of  which  are,  however,  doubtful, 
they  may,  with  advantage,  be  combined  with  iron  and  vegetable 
tonics,  as  in  the  following  prescriptions: 

R. —  Potassii  iodidi,  giij. 
Ferri  iodidi  syr.  Jij. 
Tr.  calombae,  gvj. — M. 
A  dessertspoonful  (jij)  in  water  three  times  a  day. 

R. — Potassii  bromidi,  gv. 
Yini  ferri  dulcis,  §iv. 
Tr.  caloml  88,  §iv. — M. 
A  dessertspoonful  in  water  three  times  a  day. 

Should  colleciioiis  of  pus  or  serum  be  evacuattd  ?  The  important 
bearings  of  this  question  are  manifest,  but  unfortunately  no  definite 
answer  can  be  given  to  it.  In  evacuating  these  collections  the 
peritoneal  cavity  is  not  exposed  to  entrance  of  air,  for  a  false 
membranous  roof  covers  the  collection,  but  there  is  always  danger 


PELVIC    ABSCESS.  481 

in  perforating  the  delicate  and  easily  inflamed  serous  sac.  I  have 
elsewhere  reported  a  case  in  which  I  drew  off*  one  or  two  ounces 
of  serum  under  these  circumstances,  to  the  great  relief  of  the 
patient,  who  rapidly  improved  and  did  well.  It  is  the  only  case 
in  which  I  have  ventured  to  invade  the  peritoneum  under  these 
circumstances,  though  I  have  frequently  evacuated  pelvic  ahscesses 
resulting  from  cellulitis.  The  safest  rule  for  practice  will  he  this: 
if  in  spite  of  the  sero-purulent  collection  the  patient  he  doing  well 
and  do  not  sufter  from  the  local  trouhle,  it  should  be  left  to  empty 
itself  spontaneously.  If,  on  the  other  hand,  the  patient  suffer 
from  the  collection  and  he  not  progressing  favorably,  it  should  be 
evacuated. 

Methods  of  Evacuation}. — Evacuation  may  be  accomplished  by  the 
aspirator,  a  small  trocar  and  canula,  or  by  a  guarded  bistoury  or 
tenotomy  knife.  After  evacuation  the  sac  may  be  carefully  washed 
out  with  a  weak  solution  of  carbolic  acid  in  warm  water,  or  of  tr. 
of  iodine  in  the  same  menstruum. 


CHAPTER    XXIX. 


PELVIC  ABSCESS. 


Surprise  may  be  felt  at  the  appropriation  of  a  special  chapter  to 
this  subject.  The  opinions  of  several  reviewers  have  already  been 
expressed  to  this  effect,  and  the  propriety  of  making  it  an  adden- 
dum to  that  on  cellulitis  or  peritonitis  has  been  suggested.  How 
could  this,  however,  with  propriety  be  done,  when  pelvic  abscess 
arises  from  other  than  those  inflammatory  processes ;  from  ovaritis, 
perirectitis,  psoas  disease,  disease  of  the  pelvic  bones,  etc.?  It 
appears  to  me  a  matter  of  importance  to  impress  the  fact  that  it 
should  be  viewed  from  a  more  general  stand-point  and  not  be 
limited  to  the  results  of  two  affections.  I  know  of  no  surer  way 
of  effecting  this  object  that  that  which  I  here  pursue. 

Definition. — Upon  this  point  little  need  be  said,  as  an}^  purulent 
collection  originating  in,  and  not  simply  passing  through,  the 
pelvis,  comes  under  this  head,  regardless  of  its  cause. 

Pathology. — There  are  three  sources  of  pelvic  abscess :  Ist, 
31 


482  PELVIC    ABSCESS. 

breaking  down  of  tuberculous  material  deposited  in  any  of  the 
tissues  of  the  pelvis ;  2d,  suppurative  action  taking  place  in  the 
walls  of  a  cavity  formed  by  an  hematocele  or  ovarian  cyst ;  3d, 
inflammatory  suppuration  in  the  areolar  tissue,  the  ovaries,  the 
tubes,  the  pelvic  peritoneum,  or  the  parenchyma  of  the  uterus 
itself.  Of  all  these  sources  the  third  is  decidedly  the  most  fre- 
quently met  with,  and  is  most  generally  the  result  of  cellulitis, 
occurring  after  parturition  or  in  the  non-puerperal  state.  Under 
the  latter  circumstances  cellular  inflammation  may  be  primary,  or 
secondary  to  irritation  from  some  foreign  body,  as  the  debris  of 
an  extra-uterine  foetus,  a  hard  substance  in  the  vermiform  appen- 
dix, a  fibrous  tumor  of  the  uterus,  or  caries  of  the  pelvic  bones. 

Causes. — Any  influence  which  induces  cellulitis,  or  either  of 
the  otlier  two  j^athological  conditions  mentioned,  may  prove  im- 
mediately causative  of  abscess.  As  remote  causes  may  Ije  men- 
tioned the  tuberculous,  scrofulous,  and  syphilitic  diathesis ;  great 
depression  of  the  vital  energies  from  any  cause,  as  impure  air,  like 
that  of  a  hospital ;  the  puerjieral  state ;  and  pyaemia. 

Symptoms. — These  will  not  difler  essentially  from  those  of  ab- 
scess elsewhere.  When  pus  is  forming,  violent  chills,  followed 
by  fever,  with  profuse  sweating,  are  likely  to  occur.  Then  a 
feeling  of  prostration  with  throbbing  pain  in  the  pelvis,  ])ressure 
upon  the  rectum  and  bladder,  and  sometimes  interference  with 
urination,  present  themselves.  Pain  down  the  thigh,  which  may 
be  mistaken  for  sciatica,  will  also  at  times  be  noticed. 

Physical  Signs. — By  abdominal  palpation,  combined  with  rectal 
or  vaginal  touch,  a  fluctuating  tumor  will  be  felt,  presenting  the 
ordinary  physical  signs  of  purulent  collections  elsewhere. 

Course,  Duration^  and  Termination. — Pelvic  abscesses  may  evacu- 
ate themselves  through  any  part  of  the  floor  of  the  pelvis,  through 
its  roof  into  the  peritoneum,  through  an}'  one  of  its  walls  by 
means  of  foramina,  through  any  of  the  pelvic  viscera,  or  by  several 
of  these  channels  at  the  same  time.  They  may  open  by  free  out- 
let or  by  a  long  sinuous  tract,  which  renders  prognosis  as  to  cure 
extremely  grave.  The  most  favorable  jioints  for  evacuation  arc 
through  the  vagina  and  rectum.  Next  to  these  comes,  in  point 
of  favorable  prognosis,  evacuation  through  the  abdominal  walls. 
Nonat  declares  that  when  the  collection  "  opens  simultaneously 
into  the  intestine  and  bladder,  death  is  almost  inevitable."  In 
the  "Charleston  Medical  Journal,"  for  1853,1  published  a  fatal 
case  of  this  character  with  autopsy.  Sometimes,  when  left  to 
themselves,  these  abscesses  will  go  on  to  recovery  without  delay, 


DIFFERENTIATION.  483 

opening  into  and  discharging  themselves  through  some  of  the 
parts  mentioned  and  gradually  contracting  and  disappearing. 
Sometimes,  if  deprived  of  the  assistance  of  art,  they  may  burrow 
deeply  into  the  tissues,  open  by  long,  fistulous  tracts  into  some 
organ,  as  the  large  intestine  or  sigmoid  flexure,  or  discharge  into 
the  peritoneum. 

Konig  has  instituted  some  very  interesting  experiments  on  the 
cadaver,  to  show  the  most  probable  routes  which  these  accumula- 
tions may  take : 

1st.  Injecting  air  or  water  beneath  the  peritoneum  near  the 
ovary  or  tubes,  the  injection  ran  along  psoas  and  iliac  muscles  into 
pelvis. 

2d.  Beneath  lateral  ligament  near  cervix,  it  filled  the  same  side 
of  pelvis,  ran  along  round  ligament  towards  Poupart's  ligament, 
and  to  the  iliac  fossa. 

3d.  Beneath  broad  ligament  behind  cervix,  it  filled  posterior 
and  lateral  part  of  pelvis,  and  passed  along  psoas  and  iliac  muscles 
into  pelvis. 

Sometimes,  even  when  the  opening  at  first  is  large,  it  contracts 
so  as  to  allow  only  an  imperfect  discharge  of  the  contents  of  the 
sac.  Then  hectic  fever  arises,  and  the  patient  either  leads  a  miser- 
able existence  for  years  from  the  constant  fetid  flow,  or  is  worn 
out  by  exhaustion  or  septicaemia.  At  other  times  these  collec- 
tions of  pus  will  remain  imprisoned  for  a  long  period,  without  any 
attempt  at  escape. 

Differentiation. — The  morbid  states  with  which  this  condition 
may  be  confounded  are  these : 

Pelvic  hematocele  ; 
Extra-uterine  pregnancy ; 
Displaced  ovarian  cyst ; 
Hydrometra ; 
Tubal  dropsy. 

The  first  of  these,  being  a  hemorrhage,  gives  certain  symptoms 
characteristic  of  that  accident,  as  prostration,  coldness  of  the  sur- 
face, suddenness  of  appearance,  etc.;  and  absence  of  chill,  heat, 
fever,  and  other  signs  which  are  likely  to  accompany  abscess. 

With  the  second,  the  signs  of  pregnancy  exist,  and  as  early  as 
the  fourth  month  foetal  movements  may  be  detected,  while  the 
perfect  health  of  the  patient  with  absence  of  menstruation  will 
excite  suspicion  as  to  the  character  of  the  affection. 


484  PELVIC    ABSCESS. 

Around  abscesses,  even  of  tubercular  ebaracter,  there  is  always 
a  wall  of  lymph  thrown  up  which  would  not  be  present  in  a  dis- 
placed ovarian  cyst.  All  the  rational  signs  of  suppuration  would 
likewise  be  absent  in  the  latter. 

He  who  confounds  the  distended  body  of  the  womb  with  abscess 
would  surely  be  very  culpable,  for  the  spherical  shape  of  the  body 
and  the  light  obtainable  from  the  uterine  probe  should  be  guides 
by  which  to  avoid  error. 

Tubal  dropsy  is  generally  the  result  of  inflammatory  action 
affecting  the  Fallopian  tubes  and  closing  both  uterine  and  ovarian 
extremities,  at  the  same  time  that  it  causes  a  secretion,  which 
distends  the  intermediate  canal.  The  fluctuating  tumor  tlius  re- 
sulting, being  produced  by  inflammation,  and  being  often  attached, 
in  consequence,  to  the  surrounding  parts,  would  offer  difliculties 
in  diagnosis  wliich  might  well  prove  insurmountable.  If  an  error 
were  made,  however,  no  evil  would  result  from  it. 

Prognosis. — The  jirognosis  will  depend  upon  the  following  cir- 
cumstances: it  will  be  favorable  if  the  abscess  be  superficial, 
point  upon  a  mucous  tract,  open  low  down  in  the  pelvis  by  free 
exit,  and  give  forth  pus  whicli  has  no  oft'ensive  odor.  Should 
it  be  deep-seated,  open  by  a  long  tract,  give  forth  fetid  pus,  open 
high  up  and  by  two  points  of  exit,  as,  for  example,  the  bladder 
and  bowel,  or  abdominal  wall  and  bowel,  the  prognosis  is  de- 
cidedly unfavorable,  unless  the  case  can  be  so  affected  by  surgical 
interference  as  to  change  its  character. 

Treatment. — Nothing  can  be  done  in  these  cases  by  specific 
medication,  by  which  I  mean  that  directed  especially  to  relief  of 
the  existing  morbid  condition.  All  of  our  efforts  should  be 
directed  to  supporting  the  vital  forces,  which  are  always  much 
prostrated  by  the  process  of  suppuration.  The  patient  should 
take  the  most  nutritious  diet,  as  much  animal  food  as  she  can 
digest,  eggs,  milk,  fresh  vegetables,  and  malt  liquors.  Whiskey 
or  brandy  should  be  allowed  her,  and  the  blood  state  should  be 
improved  as  much  as  possible  by  vegetable  and  mineral  tonics. 
Those  most  especially  suited  to  the  condition  are  preparations  of 
cinchona,  and  of  iron,  as,  for  instance,  the  following  pill : 

R. — Quinise  sulphat.  ^ij. 

Ferri  sulphat.  9j. 

Acid,  sulph.  arom.  gtt.  x. 

Mucilage  acaciae,  q.  s. — M.  et  ft.  pil.  No.  xx. 
S. — One  to  be  taken  three  times  a  day  before  meals. 

But  it  is  to  surgery  that  we  must  look  most  confidently  for  aid. 


TREATMENT.  485 

and  in  this  connection  arises  the  important  question  as  to  the 
propriety  of  opening  such  abscesses,  the  best  point  for  evacuation, 
and  the  time  for  interference. 

Should  an  abscess  in  the  pelvis  show  a  rapid  tendency  to  point 
and  discharge  through  a  favorable  channel,  at  the  same  time  that 
no  distressing  or  dangerous  symptoms  show  themselves,  it  would 
be  the  part  of  wisdom  to  await  the  action  of  nature,  for  all  must 
admit  that  there  are  few  localities  in  the  body  into  which  it  is 
more  hazardous  to  cut  than  this.  Even  under  these  circumstances, 
however,  there  is  danger  in  delay.  Sir  James  Simpson  relates  a 
case  which  he  saw  with  Dr.  Zeigler  one  day  when  the  abscess 
pointed  decidedly  towards  the  vagina  and  rectum  very  low  down. 
Feeling  sure  that  it  must  soon  discharge,  they  left  it  till  tlie  next 
day,  but  before  that  time,  to  their  surprise,  it  had  burst  into  the 
peritoneum.  This  danger,  as  evidenced  by  statistics,  is  not  great, 
and  as  experience  goes  to  prove  that  the  knife  is  often  employed 
too  early,  rather  than  too  late,  I  should  strongly  recommend  the 
delay  of  surgical  interference  until  the  presence  of  pus  is  an  abso- 
lute certainty.  If  it  be  thus  delayed,  the  tissues  intervening  be- 
tween the  pus  and  the  point  of  introduction  of  the  instrument 
become  broken  down,  and  a  tract  or  sinus  is  avoided ;  if  two  or 
three  abscesses  exist  near  each  other,  we  give  time  for  them  to 
coalesce ;  and  the  mass  of  lymph  poured  out  is  liquefied  by  the 
suppurative  process.  Should  evacuation  be  resorted  to  too  soon, 
all  these  advantages  will  be  lost. 

Let  us  suppose  a  dififerent  case,  that  the  patient  is  suffering  grave 
constitutional  signs  from  the  abscess.  The  answer  to  the  question 
of  the  propriety  of  interference  resolves  itself  into  this :  if  the  pus 
can  be  certainly  reached,  it  should  be  evacuated.  Should  the 
abscess  be  deeply  seated,  on  the  other  hand,  so  as  to  make  the  ope- 
ration difficult  and  uncertain,  it  would  expose  the  patient  to 
hazards  greater  than  those  attendant  upon  delay. 

Dr.  Savage  believes  that  "  puncture  should  be  practised  early 
and  per  vaginam."  Spencer  Wells  declares  from  an  experience 
in  opening  as  many  as  from  twenty  to  thirty  pelvic  abscesses  that 
he  has  known  of  no  fatal  result.  "  I  have  known,"  says  he,  "  several 
cases  of  death  where  no  puncture  has  been  made — some  of  them 
very  painful  cases — when  I  had  urged  puncture  and  was  over- 
ruled."    As  a  rule  he  punctures  per  vaginam. 

This  subject  is  one  upon  which  no  fixed  rule  can  be  given.  The 
surgeon  must  weigh  the  dangers  of  operation  with  those  of  delay, 
and  decide  by  the  indications  presenting  in  each  individual  case. 


486  PELVIC    ABSCESS. 

The  Best  Point  for  Evacuation. — To  wliatever  surface  the  point 
of  the  abscess  is  nearest,  that  will,  as  a  general  rule,  be  the  best 
for  its  evacuation.  If  there  be  a  choice,  the  locations  at  which  it 
will  most  likely  point  should  be  chosen  in  this  order:  1st,  the 
vagina ;  2d,  the  rectum ;  3d,  the  abdominal  walls. 

Dr.  Savage  reports  the  points  of  opening,  artificial  or  spontaneous, 
in  19  cases ;  they  were  as  follows : 

1  above  pubes  at  median  line. 

1  midway  between  navel  and  pubes. 

1  outside  left  saphenous  opening. 

2  by  rectum ;  1  fatal. 
1  by  rectum  and  side  of  anus. 

1  by  colon  ;  1  fatal. 
4  by  vagina. 

2  by  bladder. 

1  by  iliac  region. 

3  into  peritoneum ;  3  fatal. 

1  by  rectum  and  internal  abdominal  ring. 

1  by  vagina,  bladder,  rectum,  and  inguinal  region. 

It  will  be  seen  that  out  of  19  cases  5  proved  fatal ;  3  by  empty- 
ing into  the  peritoneum,  and  2  by  causing  colitis  and  rectitis. 

Methods  of  Operating. — The  propriety  of  opening  the  abscess 
having  been  determined  upon,  the  operator,  if  he  intend  reaching 
it  through  the  vagina  or  rectum,  should  carefully  investigate,  by 
touch,  as  to  the  presence  upon  their  w^alls  of  large  bloodvessels, 
the  opening  of  which  might  prove  a  source  of  serious  hemorrhage. 
The  patient  being  placed  on  the  left  side  and  Sims's  speculum  in- 
troduced, if  there  exist  the  slightest  doubt  as  to  the  contents  of 
the  sac  the  needle  of  a  hypodermic  syringe  should  be  plunged  into 
it  and  the  point  decided.  If  this  be  not  done  an  ordinary  ex- 
ploring needle  should  be  passed  into  the  tissues  until  pus  is  seen  to 
flow  along  its  groove.  Then  the  operator,  feeling  sure  of  his  ability 
to  reach  it,  holds  the  needle  in  one  hand,  while  with  the  other  he 
slides  the  point  of  a  bistoury  along  its  gutter  and  passes  it  to  the 
place  of  accumulation.  This  is  a  method  at  once  safe,  certain,  and 
effectual,  and  I  should  recommend  it  in  preference  to  any  other 
except  that  which  comes  next  to  be  considered.  If  an  aspirator 
can  be  procured  it  afi:brds  an  easy  and  effectual  means  of  emptying 
these  accumulations,  and  at  the  same  time  one  that  is  to  a  great 
extent  free  from  danger.  After  it  has  removed  all  the  fluid  which 
will  flow  its  action  should  be  reversed,  the  sac  filled  with  equal  parts 
of  tincture  of  iodine  and  water,  and  this  at  once  drawn  off  again. 
Should  reaccumulation  take  place,  the  situation  and  certainty  of 


TREATMENT.  487 

the  purulent  collection  being  established,  it  may  be  evacuated  by 
a  bistoury.  If  the  opening  made  be  large  enough  to  admit  the 
finger,  it  should  be  passed  in,  and  by  it  any  tract  leading  into  an 
adjoining  abscess  should  be  enlarged,  and  any  sloughing  tissue  met, 
removed.  After  this,  should  there  be  any  fear  of  closure  of  the 
canal  just  opened,  its  walls  may  be  touched  by  nitrate  of  silver,  or 
[tainted  with  solution  of  persulphate  of  iron,  or  a  piece  of  gum- 
elastic  catheter  or  rubber  tubing  may  be  left  in  it. 

Should  the  operator  open  any  large  vessel  in  the  vaginal  walls, 
hemorrhage  may  be  checked  by  applications  of  persulphate  of  iron, 
the  vaginal  tampon,  or,  should  these  not  prove  effectual,  the  actual 
cautery. 

If  it  be  thought  best  to  select  the  abdominal  surface  as  the  jooint 
of  evacuation,  all  danger  of  escape  of  pus  into  the  peritoneum 
should  be  avoided  by  following  the  suggestion  of  Eecamier  with 
reference  to  hepatic  cysts,  namely,  causing  adhesion  of  the  layers 
of  the  serous  membrane  by  a  nitric  acid  issue  oyer  the  point  of 
selection.  A  trocar,  the  needle  of  the  aspirator,  or  a  bistoury 
guided  by  an  exploring  needle,  may  be  plunged  through  the  centre 
of  the  issue  without  the  danger  just  mentioned. 

Meavs  for  Causing  Closure  of  the  Sac, — Sometimes,  after  the 
evacuation  of  these  abscesses,  their  sacs  will  not  close,  but,  re- 
maining open  for  months  and  even  years,  go  on  pouring  out  large 
quantities  of  pus. 

The  causes  of  their  not  closing  are  these:  the  existence  of  sinuses, 
which  will  not  allow  their  complete  evacuation;  a  pecuiiar  con- 
dition of  their  walls  from  the  existence  of  a  membrane,  called  by 
Delpech  pyogenic,  which  tends  to  prolong  suppuration;  or  the 
passage  into  the  sac  of  air  or  feces  from  the  intestines,  or  urine 
from  the  bladder. 

Of  these  the  first  is  decidedly  the  most  frequent,  and  should  be 
met  by  dilatation  of  the  tract  leading  to  the  abscess,  by  tents  of 
laminaria,  or  enlargement  by  the  knife. 

Should  the  abscess  have  a  short  and  free  outlet,  the  sac  should 
be  injected  two  or  three  times  a  week  with  tincture  of  iodine,  at 
first  in  solution,  afterwards  pure;  or  by  solution  of  carbolic  acid. 

In  case  of  entrance  of  feces,  air,  or  urine  into  the  d  seased  part, 
a  counter-opening  should  be  made  which  will  allow  their  free  escape, 
and  the  part  kept  as  clean  as  possil)le  by  injection  of  tepid  water. 
Then  the  fecal  or  urinary  fistula  allowing  the  vicarious  discharge 
should  be  cured  by  appropriate  means. 


488  PELVIC    HEMATOCELE. 

Before  practising  any  operation  for  evacuation  of  pelvic  abscesses 
an  anaesthetic  should  always  he  administered,  as  perfect  quietude 
is  essential  to  safety. 


CHAP  TEH    XXX. 


PELVIC    HEMATOCELE. 


Definition  and  Synonyms. — Under  this  and  the  synonymous  titles 
of  retro-uterine  hematocele,  periuterine  hematoma,  and  bloody 
tumor  of  the  pelvis,  has  been  described  an  accumulation  of  blood 
in  the  pelvic  cavity  either  above  or  below  the  peritoneum. 

History. — Although  an  attempt  has  been  made  to  prove  that  the 
ancients  were  cognizant  of  this  aftection,  the  proof  of  such  a  fact  is 
not  satisfactor3\  The  earliest  allusion  made  to  it  is  contained  in 
the  works  of  Ruyscli,  of  Amsterdam,  who  wrote  in  1737.  After 
this,  little  attention  was  paid  to  it  until  the  time  of  Eecamier, 
although  mention  of  it  was  made  by  Frank,  Deneux,  and  some 
others. 

In  1831,  Eecamier,  under  the  impression  that  he  was  opening  an 
abscess,  cut  into  a  tumor  behind  the  uterus  and  gave  exit  to  a 
large  amount  of  black,  grumous  blood,  and  about  ten  ^^ears  after- 
wards Bourdon,  one  of  his  pupils,  published  another  case  occur- 
ring in  his  practice. 

A  tabular  view  of  the  names  of  those  who  have  been  chiefly 
instrumental  in  elucidating  the  subject  and  systematizing  our 
knowledge  upon  it  is  here  presented: 

Recamier,  1831,  "  Lancette  Frangaise  ;" 

Velpeau,  1843,  ''  Recherches  sur  les  Cavites  Closes ;" 

Bernutz,  1848,  '  Archives  de  Medecine ;" 

Vigues,  1850,  "  Des  Tumeurs  Sanguines  de  I'Excav.  Pelvienne ;" 

Nelaton,  1851,  "Gazette  des  Hopitaux  ;" 

Nonat,  1851,  "  Theses  de  Cestan,  Gallardo,  et  Frost ;" 

Huguier,  1851,  Lecture  before  Surgical  Society  of  Faris ; 

Gallard,  1855,  "Union  Medicale  ;" 

Voisin,  1858,  "  De  I'Hematocele  Retro-Uterine." 

I  have  not  endeavored  to  record  the  names  of  all  who  have 
made  valuable  contributions  in  France,  for  had  I  done  so,  the  list 


PATHOLOGY.  489 

would  have  been  a  long  one.  Those  only  are  referred  to  who 
have  been  foremost  in  advancing  our  knowledge. 

It  will  thus  be  seen  that  we  are  indebted  to  France  for  the 
early  literature  of  pelvic  hematocele.  Germany  has  of  later  years 
contributed  a  great  deal  towards  it  through  the  labors  of  Olshausen, 
Credd,  Braun,  Hegar,  Virchow,  Schroeder,  Seiftert,  and  others ;  and 
England  through  those  of  Madge,  McClintock,  and  Tuckwell.  In 
America,  Prof.  Gunning  S.  Bedford  reported  the  first  case  which  I 
can  find  recorded.  More  recently,  we  are  indebted  to  Dr.  Byrne, 
of  Brooklyn,  for  a  faithful  report  of  several  cases.  Prior  to  the 
year  1851,  although  it  had  attracted  some  attention,  it  was  not 
well  understood  even  in  France,  for,  in  1850,  we  find  Malgaigne 
cutting  into  an  hematocele  under  the  impression  that  he  was  enu- 
cleating a  fibrous  tumor,  and  losing  his  patient  from  hemorrhage. 

Frequency. — This  subject  is  not  fully  settled,  a  good  deal  of  dis- 
crepancy of  opinion  existing  concerning  it.  Prof.  Olshausen,  of 
Halle,  declares  that  in  1145  gynecological  cases  he  saw  34  hemato- 
celes, and  Seifiert,  of  Prague,  reports  66  seen  in  1272  cases  of  pelvic 
female  diseases.  In  ten  years  Dr.  Barnes  has  met  with  53  cases, 
and  in  twenty  years  Dr.  Tilt  has  seen  but  12. 

I  do  not  regard  the  disease  as  being,  by  any  means,  very  rare, 
but  my  experience  assures  me  that  many  cases  of  cellulitis  and  a 
certain  number  of  uterine  and  periuterine  tumors  are  reported  as 
those  of  hematocele. 

Pathology. — The  definition  of  hematocele  has  no  relation  what- 
ever to  the  cause  of  the  hemorrhage  which  gives  material  for  the 
V)loody  tumor.  The  disease  consists  in  the  collection  of  a  mass  of 
Ijlood  in  the  pelvis,  either  above  or  below  its  roof.  Whatever  be 
its  source,  such  a  collection  constitutes  the  affection  which  engages 
us.  Ordinarily,  we  find  that  the  flow  giving  rise  to  it  takes  its 
origin  from  one  of  the  three  following  sources: 

1st.  Direct  escape  of  blood  from  vessels  in  or  near  the  pelvis ; 
2d.  Reflux  of  blood  from  the  uterus  or  tubes ; 
3d.  Transudation  of  blood  in  consequence  of  dyscrasia  or  peri- 
tonitis. 

It  is  evident  that  hematocele  is  not  a  disease,  but  a  symptom  of 
a  number  of  pathological  conditions.  As,  however,  the  source  of 
the  hemorrhage  which  results  in  the  bloody  tumor  very  often 
cannot  be  ascertained,  we  are  forced  to  deal  with  its  most  promi- 
nent and  significant  sign,  taking  this  as  an  exponent  of  a  state 
which  is  beyond  the  possibility  of  diagnosis. 


490  PELVIC    HEMATOCELE. 

In  works  upon  practice  written  twenty  years  ago,  we  find  dropsy 
treated  of  as  a  disease.  In  tliose  of  to-day  it  is  regarded  only  as  a 
legitimate  result  of  renal,  cardiac,  or  hepatic  disease.  Obstetric 
writers,  even  as  late  as  ten  years  ago,  described  puerperal  convul- 
sions as  a  disease  incident  to  parturition.  Those  writing  ten  years 
hence  will  probably  regard  them,  as  many  do  to-day,  as  one  of  the 
numerous  consequences  of  renal  disease.  "We  may  with  good  reason 
hope  that  the  time  will  come  when  a  similar  improvement  in 
description,  based  upon  an  advance  in  our  knowledge  of  pathology, 
may  connect  itself  with  hematocele,  but  at  present  the  discovery 
of  the  source  of  the  hemorrhage  is  usually  impossible. 

The  special  sources  of  the  hemorrhage  inducing  the  affection, 
which  have  been  revealed  by  post-mortem  examinations,  may  thus 
be  presented  at  a  glance: 

1.  Rupture  of  bloodvessels  in  the  pelvis. 

Utero-ovarian ; 

Varicose  veins  of  broad  ligaments ; 

Aneurism  of  artery ; 

Vessels  of  extra-uterine  ovisac. 

2.  Rupture  of  pelvic  viscera. 

Ovaries ; 
Fallopian  tubes ; 

Uterus. 

3.  Reflux  of  blood  frorn  the  uterus. 

Reflux  of  menstrual  blood. 

4.  Transudation  from  bloodvessels. 

Purpura ; 
Scorbutus ; 
Chlorosis ; 
Hemorrhagic  peritonitis. 

All  of  these  causes  have  been  proved  by  post-mortem  research 
to  have  resulted  in  hematocele,  but  it  cannot  be  questioned  that 
rupture  of  any  bloodvessel  which  empties  its  contents  into  the 
peritoneum  might  also  do  so.  Blood  poured  into  the  peritoneum 
from  rupture  of  the  spleen,  for  example,  would  gravitate  towards 
Douglas's  cul-de-sac,  because  it  is  the  most  dependent  portion  of 
that  membrane,  and  coagulating  would  give  all  the  signs 'of  a 
bloody  tumor  in  that  locality.  At  times  the  affection  is  indicative 
of  serious  internal  lesion,  rupture  of  the  ovary  or  tube;  at  others 
it  results  merely  from  imperviousness  of  the  cervical  or  tubal  canal, 


CAUSES.  491 

which  prevents  the  advance  of  menstrual  blood  and  causes  it  to 
regurgitate  into  the  peritoneum ;  while  in  still  a  third  class  of 
cases,  it  is  created  by  pouring  out  of  blood  from  the  vessels  of  the 
peritoneum.  The  last  condition  has  been  described  as  hemorrhagic 
peritonitis,  and  especially  pointed  out  by  Virchow.  Schroeder  be- 
lieves that  peritonitis  always  precedes  the  occurrence  of  hemato- 
cele. That  it  usually  accompanies  it  is  unquestionable,  but  if  it  be 
a  precursor  of  this  aftection,  which  suddenly  bursts  forth  upon  a 
patient  apparently  in  good  health,  it  tells  badly  for  our  means  of 
diagnosis  of  pelvic  peritonitis.  It  is  undeniable,  however,  that 
in  some  cases  hematocele  does  follow  and  not  precede  the  peri- 
tonitis. 

Whatever  be  the  source  of  the  blood,  it  collects  either  in  the 
most  dependent  part  of  the  peritoneum,  or  in  the  pelvic  areolar 
tissue  beneath  it.  Here  it  remains  for  a  time  fluid,  then  under- 
goes partial  coagulation,  becoming  a  grumous  mass  like  currant 
jelly,  and  lastly,  all  the  fluid  being  absorbed,  a  hard,  resisting 
tumor  composed  of  fibrinous  material  remains.  Should  the  collec- 
tion have  occurred  in  the  peritoneum,  its  boundaries  will  be  the 
walls  of  that  cavity  laterally  and  below,  while  a  localized  perito- 
nitis forms  for  it  a  roof  of  effused  lymph.  If  it  collect  in  the 
areolar  tissue  of  the  pelvis,  the  effused  blood  will  make  its  own 
nidus  by  percolating  the  loose  structure  and  mechanically  creating 
a  space  in  it. 

In  either  of  these  positions  it  is  entirely  absorbed  and  reduced  to 
a  hard,  firm  tumor,  which  remains  for  a  long  time,  or  is  discharged 
by  the  vagina  or  rectum,  or  into  the  peritoneum.  The  last  point 
of  evacuation  is  fortunately  rare.  Nonat^  quotes  Dupuytren  for 
the  following  very  ingenious  and  plausible  explanation  of  the 
method  of  such  absorption,  which  he  likens  to  the  process  of  diges- 
tion. The  vessels  of  the  cyst  which  are  in  contact  with  the  mass 
remove  its  fluid  portion,  and  thus  its  hard  surface  comes  in  ap- 
position with  the  sac.  This  excites  eftusion  of  serum,  which 
softens  the  fibrinous  wall  and  renders  it  susceptible  of  absorption, 
which  soon  occurs.  Then  again  contact  excites  a  flow  of  fluid, 
and  again  this  is  removed,  until  the  whole  mass  is  diminished  or 
completely  absorbed. 

Causes. — A  glance  at  the  recognized  causes  of  the  disease  will 
make  it  evident  that  congestion  of  the  pelvic  organs  must,  in  an 
eminent  degree,  predispose  to  it.    This  explains  the  fact  that  it  has 

'  Op.  cit.,  p.  344. 


492 


PELVIC    HEMATOCELE. 


been  found  to  have  occurred  most  frequently  during  the  period  of 
ovarian  activity  and  especially  during  a  menstrual  epoch. 

The  predisposing  causes  are — 

The  period  of  ovarian  activity,  15  to  45"; 

Disordered  blood  state,  plethora  or  anaemia; 

The  menstrual  epoch ; 

Chronic  uterine  or  ovarian  disease ; 

The  hemorrhagic  diathesis. 

The  exciting  causes  are — 

Sudden  checking  of  menstrual  flow; 
Blows  or  falls ; 

Excessive  or  intemperate  coition; 
Obstruction  of  cervical  canal ; 
Obstruction  of  Fallopian  tubes ; 
Violent  eftbrts. 

Varieties. — There  are  two  forms  of  the  aftection,  subperitoneal 
and  peritoneal.     In  the  latter,  the  blood  tumor  forms  within  the 

Fig.  141. 


Peritoneal  Hematocele.    (Barnes.) 


peritoneum,  where  it  in  time  becomes  encysted  unless  death  occur 
at  an  early  period.  In  the  former,  it  occurs  in  the  areolar  tissue 
of  the  pelvis,  under  the  peritoneum. 


SYMPTOMS.  493 

The  propriety  of  the  consideration  of  the  former  under  the  same 
head  as  the  latter,  has  been  contested  by  Aran,  Bernutz,  and  Voisin, 
but  from  a  clinical  stand-point  it  appears  to  be  quite  valid.  Not 
only  have  distinct  instances  of  subperitoneal  hematocele  been 
recorded  by  such  observers  as  Simpson,  Olshausen,  Tuckwell,  and 
Barnes ;  cases  have,  likewise,  presented  themselves,  which  com- 
mencing as  subperitoneal  ones  have  ruptured  the  peritoneal  cover- 
ing of  the  pelvis,  and  thus  broken  down  the  theoretical  barrier 
which  pathologists  have  been  inclined  to  establish  between  the  two 
varieties. 

Of  the  two  varieties  the  peritoneal  is  much  the  more  frequent, 
at  the  same  time  that  it  is  the  more  grave.  In  41  autopsies  Tuck- 
well  found  the  tumor  to  be  peritoneal  in  thirty-eight.  In  a  case 
which  I  saw  with  Dr.  Emmet  about  a  year  ago,  we  w^ere  unable  to 
make  a  diagnosis  of  a  tumor  which  lay  obliquely  anterior  to  the 
uterus.  In  twenty-four  hours  the  patient  fell  into  a  state  of  col- 
lapse, and  as  we  saw  her  thus,  the  nature  of  the  tumor,  which  we 
were  doubtful  about  on  the  previous  day,  became  evident.  Upon 
a  post-mortem  examination  an  ante-uterine  hematocele  as  large  as 
a  goose's  egg  was  found  under  the  peritoneum,  through  which  it 
had  broken,  discharged  a  portion  of  its  contents  into  the  perito- 
neum, and  caused  collapse  and  death.  This  is  the  only  ante-uterine, 
but  not  the  only  subperitoneal  hematocele,  with  which  I  have  met. 

Sym'pioms. — The  absolute  occurrence  of  hemorrhage  is  generally 
preceded  by  symptoms  which  are  premonitory,  as  fixed,  dull  pain 
over  the  ovaries,  derangement  of  menstruation,  metrorrhagia,  or 
prolongation  of  the  menstrual  discharge.  The  symjitoms  of  the 
actual  escape  of  blood  will  depend  in  great  degree  upon  the  nature 
and  gravity  of  the  accident  which  has  given  rise  to  it. 

Sometimes  the  affection  occurs  without  any  violent  symptoms 
and  almost  without  warning.  It  will  be  appreciated  that  this 
would  be  so  if  it  were  due  to  gradual  reflux  of  blood  on  account  of 
constricted  cervix,  or  transudation,  the  result  of  purpura.  Fre- 
quently a  sudden  manifestation  of  symptoms  occurs,  and  the  acci- 
dent is  announced  as  rapidly  as  is  cerebral  apoplexy. 

It  is  evident,  then,  that  the  symptoms  must  differ  widely  in 
cases  marked  by  very  great  and  sudden  loss  of  blood,  and  those 
accompanied  by  very  little.  In  the  first  there  are  evidences  of 
profuse  abstraction  of  vital  fluid,  great  peritoneal  shock,  and  ex- 
cessive prostration.  In  the  second  these  may  all  be  so  slight  as  to 
escape  the  notice  of  non-observant  patients.  The  l)ost  course 
which  can  be  pursued  in  reference  to  the  matter  is,  I  think,  to  take, 


494  PELVIC    HEMATOCELE. 

as  an  example,  a  case  of  moderate  severity,  and  guard  the  reader 
against  supposing  that  all  attacks  give  the  same  degree  of  intensity 
of  symptoms. 

Most  prominent  among  the  symptoms  are — 

Severe  pain  in  the  pelvis  ; 

Pallor,  faintness,  and  coldness  of  extremities ; 

Sense  of  exhaustion ; 

Nausea  and  vomiting ; 

Metrorrhagia ; 

Uterine  tenesmus ; 

Tympanites ; 

Interference  with  bladder  and  rectum  ; 

Small  and  rapid  pulse  ; 

Depressed  thermometric  range. 

.  The  patient  feels  as  if  a  large  and  heavy  body  exists  in  the 
pelvis,  and  instinctively  strives  to  expel  it  by  the  vagina.  At 
times  the  pain  complained  of  is  very  acute ;  at  others  it  is  a  dull 
and  heavy  aching. 

After  a  variable  time,  generally  within  forty-eight  hours,  a 
reaction  from  this  state  of  prostration  occurs.  Sometimes  this  is 
slight ;  at  others  decided.  It  is  dependent  chiefly  upon  the  degree 
of  inflammation  set  up  by  the  sanguineous  accumulation  acting  as 
a  foreign  body.    This  is  usually  marked  by  the  following  symptoms : 

Tendency  to  chilliness ; 
Constipation ; 
Suppression  of  urine ; 
Great  tympanites ; 
Heat  of  skin ; 
High  thermometric  range ; 
Rapid  pulse ; 
Tenderness  over  abdomen. 

All  these  symptoms  point  to  two  facts :  Ist,  sudden  and  exces- 
sive loss  of  blood ;  2d,  the  existence  of  some  substance  in  the 
pelvis  which  mechanically  interferes  with  its  viscera.  A  part  of 
them  might  be  produced  by  menorrhagia,  a  part  by  sudden  retro- 
version ;  but  a  union  of  the  whole  will  strongly  excite  suspicion 
of  hematocele,  and  call  for  a  physical  exploration. 

Physical  Signs. — Vaginal  touch  reveals  a  tumor  usually  posterior 
to  uterus  and  vagina,  and  generally  partially  closing  the  latter. 
The  mass  thus  felt,  if  the  examination  be  made  within  a  day  or 
two  after  its  formation,  will  be  found  to  be  soft,  smooth,  and  ob- 


DIFFERENTIATION.  495 

scurelj  fluctuating.  If  a  number  of  days  liave  elapsed  before  it 
be  touched,  it  will  give  the  impression  of  irregularity,  due  to 
coagula  surrounded  by  fluid  blood.  The  uterus  will  be  found 
pressed  out  of  its  position,  generally  upwards  and  forwards,  so 
that  the  cervix  will  be  above  the  symphysis.  Sometimes,  however, 
it  is  forced  out  of  the  median  line  to  one  side. 

]^onat'  dogmatically  announces  that  the  uterus  is  never  found 
between  the  tumor  and  the  rectum,  that  is  to  say,  behind  the  mass 
of  blood;  but  Chassaignac^  reports  a  case  in  which  the  sanguineous 
collection  existed  entirely  between  the  bladder  and  uterus,  and 
consequently  must  have  forced  that  organ  backwards;  and  similar 
cases  are  recorded  by  G.  Braun,  Olshausen,  Barnes,  myself,  and  others. 
Rectal  touch  will  show  that  the  bowel  is  closed  by  pressure  from 
the  tumor. 

Abdominal  palpation  will  reveal  the  presence  of  a  hard  mass 
which  may  extend  only  up  to  the  superior  strait,  or  as  high  as 
the  navel.  In  cases  where  a  small  quantity  of  blood  has  been 
effused,  and  more  especially  where  this  has  collected  under  and 
not  in  the  peritoneum,  an  abdominal  tumor  may  not  be  discovered. 
By  the  aid  of  conjoined  manipulation  the  shape,  extent,  and 
character  of  the  mass  may  be  further  ascertained. 

Different iation. — ^The  diseases  with  which  hematocele  may  be 
confounded  are — 

Pelvic  cellulitis  or  abscess  ; 

Retroversion ; 

Extra-uterine  pregnancy  ; 

Fibrous  tumor ; 

Dislocated  ovarian  cyst. 

The  mass  created  by  cellulitis  and  abscess  is  usually  bound  to 
the  side  of  the  uterus,  and  not  posterior  to  that  organ ;  it  develops 
less  suddenly  than  hematocele;  is  hard  at  first,  and  gradually 
softens;  is  exquisitely  painful  to  touch;  does  not  lift  the  uterus  and 
press  it  forwards ;  and  is  not  usually  accompanied  by  metrorrhagia. 

Retroversion  may  present  the  signs  due  to  the  mechanical  results 
of  hematocele,  but  not  those  due  to  loss  of  blood.  If  pregnancy 
coexist,  conjoined  manipulation  will  usually  suffice  for  diagnosis. 
If  it  should  not,  the  uterine  probe  will  elucidate  the  case. 

Extra-uterine  pregnancy  does  not  develop  suddenly,  but  slowly, 
and  is  characterized  by  many  of  the  signs  of  pregnancy.  In  place 
if  metrorrhagia  there  is  usually,  though  not  always,  amenorrhoea. 

'  Op.  cit.,  p.  342.  2  Courty,  Mai.  de  1' Uterus,  p.  912. 


496  PELVIC    HEMATOCELE. 

Fibrous  tumors  grow  slowly,  are  painless,  and  move  with  the 
uterus.  They  are  irregular  and  hard,  and  do  not  usually  push  the 
uterus  so  far  forwards  and  upwards. 

Displaced  ovarian  cysts  are  painless,  show  no  signs  of  hemorrhage, 
and  cause  no  constitutional  disturbance  or  metrorrhagia. 

Course^  Duration^  and  Termination. — Hemorrhage  from  the 
sources  enunciated  as  those  of  hematocele,  may  be  so  great  as  to 
destroy  life  immediately.  Five  such  instances  are  recorded  by 
Voisin,  and  Ollivier  d'Angers'  mentions  two  in  which  death 
occurred  in  half  an  hour  from  rupture  of  a  varicose  utero-ovarian 
vein.  Such  a  termination  is,  however,  decidedly  exceptional. 
The  tumor  generally  disappears  by  absorption,  is  discharged  by 
the  rectum  or  vagina,  or  remains  a  hard,  indurated  mass  long 
afterwards.  Discharge  is  most  frequently  followed  by  recovery, 
but  sometimes  putrefaction  occurs  in  the  walls  of  the  sac,  septicae- 
mia takes  place,  and  death  ensues.  The  process  of  absorption  may 
be  accomplished  in  three  weeks,  or  six  months  may  elapse  before  it 
is  complete. 

In  some  cases  a  slow  and  steady  hemorrhage  appears  to  go  on 
for  weeks,  and  render  the  bloody  tumor  gradually*  larger.  In 
others  hemorrhages  subsequent  to  the  first  take  place  after  this  has 
become  encapsulated.  After  subsidence  of  the  symptoms  of  reac- 
tion, chill,  fever,  and  sweating  often  come  on  late,  marking  sup- 
puration in  the  mass,  and  slight  septic  absorption. 

Prognosis. — The  prognosis  of  hematocele  must  be  governed  in 
great  degree  by  the  amount  of  blood  lost,  the  degree  of  constitu- 
tional shock  resulting,  and  the  intensity  of  reaction  excited.  As 
a  rule  it  is  favorable;  especially  so,  I  should  say,  when  treated  upon 
the  expectant  plan,  and  not  by  immediate  surgical  interference. 

In  cases  of  peritoneal  form  a  graver  prognosis  is  called  for  than 
in  the  subperitoneal,  for  evident  reasons ;  and  where  a  great  deal 
of  blood  has  been  lost  the  dangers  are  greater  than  where  the 
amount  has  been  more  limited.  This  is  true  not  only  from  the  fact 
that  an  excessive  flow  might  cause  death  from  exhaustion,  but 
because  the  removal  of  so  large  an  amount  of  coagulum,  whether 
by  absorption  or  discharge,  must  necessarily  expose  the  j)atient  to 
great  dangers. 

When  death  occurs  it  is  usually  a  consequence  of  loss  of  blood, 
shock  from  sudden  invasion  of  the  peritoneum,  peritonitis,  rupture 
of  the  encapsulated  mass  into  the  peritoneum,  or  septicaemia. 

'  Noeggerath,  Bui.  N.  Y.  Acad.  Med.,  vol.  i,  p.  577. 


TEEATMENT.  497 

Treatment. — The  physician  will  rarely  be  called  upon  to  resort  to 
treatment  before  the  amount  of  blood  which  is  destined  to  be  lost 
has  collected  in  the  pelvis.  He  will,  however,  often  be  present  to 
witness  the  great  constitutional  disturbance  and  excessive  prostra- 
tion and  pain  which  immediately  follow  the  hemorrhage.  The 
diagnosis  being  made,  the  indications  for  treatment  will  be  simple 
enough : 

1st.  To  check  tendency  to  further  loss ; 

2d.  To  prevent  death  from  prostration ; 

3d.  To  relieve  pain. 

To  accomplish  the  first  indication,  perfect  rest  should  be  imme- 
diately secured.  The  clothes  should  be  loosened,  but  no  time  spent 
in  their  removal,  and  the  patient  kept  quiet  upon  the  back.  A 
bladder  of  ice,  or  cloths  soaked  in  cold  water,  should  be  laid  over 
the  hypogastrium ;  cold  fluids  given  to  drink  if  nausea  should  not 
exist  as  a  symptom ;  and  astringents  administered,  such  as  aromatic 
sulphuric  acid,  and  gallic  acid  in  as  free  doses  as  the  stomach  will 
tolerate. 

In  the  fulfilment  of  the  second  indication,  alcoholic  stimulants 
and  opiates  should  be  freely  used.  Iced  champagne  or  cold  brandy 
and  water  should  be  given,  and  with  them  should  be  combined  a 
solution  of  the  sulphate  of  morphia  or  some  fluid  preparation  of 
opium.  In  great  nervous  prostration,  and  more  particularly  when 
this  has  resulted  from  hemorrhage,  opium  proves  a  far  more  reliable 
and  rapid  stimulant  than  alcohol.  In  hematocele  it  is  peculiarly 
appropriate  for  the  additional  reason  that  it  accomplishes  at  the 
same  time  the  third  indication,  the  relief  of  pain. 

Should  pain  be  very  severe  or  nausea  exist,  Magendie's  solution 
of  morphia  should  be  injected  hypodermically  in  the  amount  of  ten 
minims,  which  may  be  repeated  in  thirty  minutes  if  it  fail  to  give 
relief.  The  patient  should  be  put  to  bed  and  kept  perfectly  quiet. 
The  diet  should  consist  of  fluid  food,  such  as  milk,  animal  broths, 
and  gruels  of  farina  or  sago. 

And  now  will  arise  the  important  question,  whether  the  accumu- 
lated blood  should  be  left  for  removal  by  nature,  or  should  be 
evacuated  by  surgical  means.  Rdcamier,  in  introducing  the  subject 
to  the  profession,  inaugurated  the  practice  of  evacuating  such 
tumors,  and  Nelaton  indorsed  and  popularized  it.  But  experience 
taught  I^elaton  that  the  procedure  was  not  judicious,  and  "to-day 
he  proscribes  it  in  an  almost  absolute  manner."^     Immediate  sur- 

'  Nonat,  op.  cit. 

32 


498  PELVIC    HEMATOCELE. 

gical  interference  presses  its  claims  in  consideration  of  the  facts 
that — 

1st.  It  is  capable  of  cutting  short  a  lengthy  and  dangerous  dis- 
order ; 

2d.  It  may  save  the  patient  from  the  dangers  incident  to  absorp- 
tion as  well  as  discharge ; 

3d.  It  removes  from  the  peritoneum  or  pelvic  cellular  tissue  a 
foreio;n  body,  which,  undisturbed,  would  prove  the  focus  of  in- 
flammation. 

It  is  not  surprising  that  it  was  the  favorite  plan  in  the  infancy 
of  the  subject.  When,  however,  pathologists  had  had  an  oppor- 
tunity of  studying  the  natural  history  of  the  affection,  it  was  as 
naturally  abandoned,  for  the  following  reasons : 

1st.  It  was  discovered  that,  when  not  interfered  with,  hemato- 
cele very  generally  passes  away  rapidly ; 

2d.  It  was  discovered  that  the  dangers  of  puncture  were  greater 
than  those  of  the  tumor  left  undisturbed ; 

3d.  Medical  means  were  found  to  exert  a  marked  controlling 
influence  over  its  complications. 

With  the  light  which  experience  has  thrown  upon  this  point  it 
appears  to  me  that,  without  being  dogmatic,  we  may  safely  adopt 
this  rule.  The  mere  presence  of  a  large  amount  of  blood  in  the 
peritoneum  does  not  warrant  evacuation.  If,  as  time  passes,  sup- 
puration within  the  sac,  which  has  then  pretty  certainly  become 
encapsulated,  and  septic  absorption  are  manifested  by  chills,  febrile 
action,  and  profuse  sweating,  the  softening  mass  should  be  dis- 
charged by  incision.  In  other  words,  so  long  as  the  accumulated 
blood  appears  to  be  doing  no  decided  harm  and  nature  seems  to  be 
causing  its  absorption,  it  should  be  left  alone.  But  so  soon  as  evi- 
dences of  septicaemia  are  observed,  it  should  be  evacuated.  Under 
these  circumstances,  a  neglect  of  surgical  interference  would  be 
culpable.  Without  such  indications  it  should  be  avoided,  and  re- 
liance placed  upon  medical  resources,  for  it  should  be  borne  in 
mind  that  the  collection  of  blood  is  usually  in  the  peritoneum,  and 
that  incision  of  this  membrane,  in  addition  to  its  own  inhere:it 
dangers,  would  always  expose  to  those  arising  from  admission  of 
air. 

Methods  of  Operating. — The  patient  being  placed  upon  the  back, 
as  if  for  lithotomy,  a  trocar  and  canula  may  be  held  in  the  right 
hand,  guided  to  the  most  fluctuating  and  dependent  part  of  the 
mass,  and  plunged  in.  Or,  the  patient  lying  on  the  left  side,  the 
perineum  and  posterior  vaginal  wall  may  be  lifted  by  Sims's  specu- 


FIBROID    TUMORS    OF    THE    UTERUS.  499 

lum,  and  an  incision  made  into  the  wall  of  the  tumor  by  a  teno- 
tomy knife  or  small  bistoury.  Through  the  opening  thus  made, 
one  or  two  fingers  should  be  introduced  and  the  clots  removed. 
After  evacuation  by  either  method,  the  nozzle  of  a  syringe  should 
be  introduced  into  the  sac,  and  a  stream  of  tepid  water,  or  of  this 
with  a  very  small  amount  of  carbolic  acid,  should  be  very  gently 
and  cautiously  made  to  wash  out  the  cavity  remaining.  This 
should  be  repeated  once  or  twice  in  twenty-four  hours,  for  preven- 
tion of  septicaemia. 

Medical  Treatment. — Reaction  having  taken  place,  perfect  rest 
should  be  insisted  upon.  The  patient  should  not  rise  from  bed 
even  for  the  calls  of  nature,  the  bladder  being  emptied  by  the 
catheter  and  the  bowels  kept  constipated  by  opium.  Warm  poul- 
tices of  ground  linseed  should  be  constantly  kept  over  the  hypogas- 
trium,  and  pain  should  be  quieted  by  opiates. 

After  the  abatement  of  acute  symptoms,  a  blister,  four  by  six 
inches,  should,  unless  some  contra-indication  exist,  be  applied  over 
the  hypogastrium,  and  this  may  with  advantage  be  repeated  every 
ten  or  twelve  days.  Its  results  will  often  be  very  marked,  and 
although  apparently  harsh  practice,  it  prevents  much  suffering, 
while  it  causes  but  little. 

As  time  passes  and  pain  is  relieved,  quinine,  alone  or  combined 
with  sulphuric  acid,  in  full  doses  will  prove  a  valuable  remedy,  and 
should  be  kept  up  perseveringly. 


CHAPTER    XXXI. 

MYO-FIBROMATA  OR  FIBROID  TUMORS  OF  THE  UTERUS. 

Definition  and  Synonyms. — The  parenchyma  of  the  uterus  is  liable 
'o  undergo  a  localized  hypertrophy,  which  results  in  the  produc- 
:ion  of  two  varieties  of  tumors ;  the  fibrous  and  the  fibro-cystic. 
The  first,  which  is  one  of  the  most  frequent  pathological  conditions 
o  which  this  organ  is  subject,  will  now  receive  attention,  while 
he  second  and  much  rarer  form,  will  be  treated  of  in  a  separate 
ection. 

By  the  older  writers  fibrous  tumors  were  styled  tubercula,  stea- 


500  FIBROID    TUMOES    OF    THE    UTERUS. 

tomata,  sarcomata,  etc.  Since  their  true  nature  has  been  more 
carefully  studied  by  aid  of  the  microscope  and  been  understood, 
they  have  been  described  under  the  names  of  fibrous  tumors, 
uterine  fibroids,  fibroma,  and  more  recently,  by  Virchow,  myoma. 
I  have  adopted  the  terms  which  head  this  chapter,  following  the 
example  of  Billroth  for  the  first,  and  of  Klob  for  the  second,  for 
the  reason  that  neither  that  of  fibroma  nor  myoma  alone,  expresses 
the  existing  pathological  condition.  Billroth^  rejects  the  latter 
name,  which  signifies  that  these  growths  consist  in  hypertrophy 
of  muscular  substance ;  and  at  the  same  time  he  refuses  to  admit 
the  former,  as  that  conveys  the  equally  incorrect  idea  that  they  are 
constructed  of  connective  tissue.  Fibroid  (Jihrosus  and  stSo?),  re- 
sembling fibrous  tissue,  is  at  least  not  calculated  to  mislead,  while 
myo-fibroma  expresses  the  exact  truth.  . 

History. — Until  the  time  of  Dr.  William  Hunter,  who  wrote 
towards  the  close  of  the  eighteenth  century,  the  true  nature  of 
uterine  fibroids  was  not  appreciated.  They  were  confounded  with 
malignant  growths,  of  which  they  were  regarded  as  a  variety.  He 
described  them  under  the  name  of  fleshy  tubercle,  and  contributed 
greatly  to  the  knowledge  of  their  pathology;  but  it  was  not  until 
the  writings  of  Chambon,^  Baillie,  Bayle,  and  others,  that  the  sub- 
ject was  fully  elucidated.  Sir  Charles  Clark,  in  1814,  wrote  an 
excellent  chapter  upon  them,  which  would  almost  answer  the 
requirements  of  our  day. 

Pathology. — Surprise  that  any  confusion  should  have  existed 
between  these  tumors  and  cancerous  growths,  will  cease  when  we 
consider  that  their  identity  is  boldly  assumed  by  so  careful  an 
observer  as  Dr.  Ashwell,  as  late  as  1844.  He  gives  five  reasons  for 
his  belief,  which  he  declares  appear  to  him,  "conclusive."  His 
reasoning  has  failed  to  convince  others,  no  writer  since  his  time 
having  adojrted  the  view  which  Dr.  Hunter  succeeded  in  abolishing, 
and  no  fact  in  gynecology  is  now  more  fully  settled  than  that  of 
the  non-malignancy  of  these  tumors. 

Until  recently  the  question  has  not  been  settled  as  to  tlie  possi- 
bility of  their  undergoing  cancerous  degeneration.  Bayle  and 
Lobstein  have  declared  that  they  never  do  so,  and  the  researches 
of  Cruveilhier  and  Lebert  tend  to  support  the  view;  while  Kiwisch, 
Atlee,^  and  Simpson,  believe  that  malignant  degeneration  occurs 
in  very  rare  cases.     "In  1862,"  says  Klob,*  "a  singular  specimen 

'  Surg.  Pathol.,  p.  583.  2  Mai.  de  I'Uterus. 

3  McClintock,  Diseases  of  Women-  ■*  Op.  cit.,  p.  173. 


PATHOLOGY.  501 

was  added  to  the  Salzburg  Museum.  From  a  fibroid  tumor  the 
size  of  a  child's  head,  situated  in  the  posterior  walls  of  the  uterus, 
carcinoma  had  undoubtedly  been  developed  without  any  other 
portion  of  the  body  being  affected,  and  I  am  therefore  constrained 
to  allow  the  possibility  of  such  a  transition,  although  I  cannot 
recall  a  second  case  of  this  kind  either  in  the  literature  of  the 
subject  or  in  my  rather  extensive  experience." 

Although  this  case  seems  to  settle  the  matter  of  possibility,  at 
leapt,  it  must  not  be  forgotten  that  beyond  doubt  such  a  change  of 
type  is  exceedingly  rare.  It  is  in  this  connection  a  fact  worthy  of 
note  that  in  the  negress,  in  whom  fibroid  tumors  are  so  common  as 
to  be  regarded  by  some  as  almost  universally  met  with  after  the 
thirtieth  year,  carcinomatous  afi:ections  of  the  uterus  are  very  rarely 
seen. 

Uterine  fibroids  may  develop  singly,  when  ordinarily  they  do  not 
attain  to  a  very  great  size.  Sometimes,  however,  they  exist  in 
great  numbers,  and  grow  to  a  very  large  size.  Courty  reports  one 
weighing  fifty  pounds,  and  I  have  removed  one,  with  uterus  and 
both  ovaries,  of  the  same  weight.  Some  years  ago  I  exhibited  to 
the  New  York  Pathological  Society,  the  uterus  of  a  negress  which 
contained  thirty-five  tumors  of  every  size  between  that  of  a  foetal 
head  and  that  of  a  marble. 

Fibroids  may  develop  in  any  part  of  the  uterus ;  but  the  usual 
site  is  in  the  body  or  fundus.  Mr.  S.  Lee  examined  seventy-four 
preparations  in  the  London  museums,  and  found  that  the  rarest  of 
all  locations  for  them  is  the  cervix.  A  very  interesting  instance 
of  a  large  tumor  developed  below  the  os  internum  is  reported  by 
Dr.  Murray,  in  the  sixth  volume  of  the  London  Obstetrical  Trans- 
actions. Their  structure  varies  very  greatly,  not  only  from  their 
original  development  being  different,  but  from  their  being  suscep- 
tible of  several  diseased  states,  which  will  very  soon  be  mentioned, 
and  which  produce  their  characteristic  alterations.  The  typical 
form  is  that  of  hard,  resisting  fibrous  tissue,  which  creaks  under 
the  knife.  Under  the  microscope  this  is  found  to  consist  of  long, 
fine  fibres,  generally  united  in  bundles;  of  fusiform  fibre-cells 
analogous  to  fibro-plastic  elements;  and  of  round  or  elliptic  granules 
of  small  size;  the  whole  being  bound  together  by  fine  intercellular 
substance. 

They  consist  of  the  hypertrophied  elements  of  the  uterus,  to 
which  organ  they  are  strictly  homologous.  In  the  majority  of 
cases,  it  is  declared  by  recent  pathological  investigators,  that  con- 
nective tissue   preponderates   in  their  construction,  but  there  is 


502 


FIBROID    TUMORS    OF    THE    UTERUS. 


always  a  certain  degree  of  muscular  hypertrophy  concerned  in  their 
development;  hence  Billroth's  objection  to  the  terms  fibroma  and 
myoma.  In  some  cases  the  amount  of  muscular  exceeds  that  of 
connective  tissue  in  their  construction.  This,  which  may  be  styled 
the  normal  type  of  the  uterine  fibroid,  is  departed  from  by  forma- 
tion of  cysts  in  the  midst  of  the  fibrous  tissue,  which  constitutes 
the  tumor  one  of  fibro-cystic  character. 


Uterine  fibroma.     Oblique  longitudinal  section  of  muscular 
cell-bundles.    (Billroth.) 

Uterine  fibroids  are  liable  to  a  variety  of  diseases,  among  which 
the  most  frequent  are  cedema;  inflammation;  gangrene;  fatty, 
colloid,  and  calcareous  degeneration ;  and  apoplexy.  The  last  con- 
sists in  rupture  of  small  bloodvessels  within  the  mass,  and  conse- 
quent accumulation  of  blood. 

Very  rarely  the  whole  mass  becomes  a  ball  of  calcareous  matter, 
which,  projecting  in  utero  and  becoming  detached,  is  sometimes 
discharged  per  vaginam.  This  is  the  disease  which  was  described 
by  old  writers  as  uterine  calculus.  The  uterine  attachment  of 
fibroids  of  compound  character  is  sometimes  the  seat  of  a  species 
of  varicose  degeneration  of  the  small  vessels,  which  causes  the 
structure  to  resemble  erectile  tissue.  Tumors  thus  affected  have 
been  styled  by  Virchow,  telangiectatic  tumors.  This  vascular 
structure  readily  bleeds,  and  in  one  case  I  saw  it  the  cause  of  a 
small  hematocele.     But  large  vessels  are  likewise  discovered  in  the 


VARIETIES    AND    CAUSES.  503 

pedicles  of  fibroids ;  Caillard  reporting  one  the  size  of  the  radiaj 
artery.  Klob  has  met  with  but  one  such  vessel,  which  was  the 
size  of  the  uterine  artery. 

Varieties. — Klob  divides  these  growths  into  two  classes — simple 
and  compound.  The  first  consists  of  one  tumor,  which  is  generally 
spherical,  and  which  is  connected  by  loose  connective  tissue  with 
the  uterus.  The  second  is  a  compound  tumor,  made  up  of  a  number 
of  small  fibroids,  connected  by  loose  connective  tissue.  The  second 
variety  is  more  vascular  than  the  first,  and  its  surface  is  nodulated 
and  not  smooth.  Both  these  classes  present  themselves  clinically 
in  three  varieties,  which  are  created  by  the  locality  of  the  growths 
in  the  walls  of  the  uterus.  If  they  lie  under  the  mucous  membrane 
projecting  into  the  uterus,  they  are  called  submucous;  if  under  the 
peritoneum,  subserous  ;  if  in  the  wall  of  the  uterus,  interstitial. 

If  a  tumor  be  situated  in  the  wall  of  the  uterus,  it  may  remain 
there  until  it  assumes  large  dimensions.  Should  it  be  near  the 
mucous  or  serous  lining,  it  is  subjected  to  contractile  efibrts  on 
the  part  of  the  surrounding  parenchyma,  which  are  excited  by  its 
presence,  and  which  often  in  time  force  it  towards  the  uterine  or 
abdominal  cavity.  Sometimes  its  connection  with  the  mother 
tissue  is  kept  up  by  a  broad  base;  sometimes  it  is  limited  to  a  long 
slender  pedicle,  which,  in  the  case  of  the  subperitoneal  varieties, 
allows  of  great  mobility.  Should  the  mass  be  forced  into  the  uterine 
cavity,  and  gradually  assume  a  slender,  pedunculated  attachment, 
it  receives  the  name  of  fibrous  polypus,  which  is  therefore  a  variety 
of  submucous  fibroid 

Subperitoneal  uterine  tumors  have  been  known  to  perform  the 
most  singular  migrations.  The  pedicle  being  broken,  they  have 
at  times  been  found  rolling  about  freely  in  the  peritoneum,  and  at 
others,  having  set  up  adhesive  inflammation,  they  have  been  found 
detached  from  the  uterus,  and  attached  to  some  other  abdominal 
viscus. 

Causes. — The  predisposing  causes,  or  rather  those  generally  re- 
garded as  such,  are : 

Race,  the  African  being  peculiarly  liable ; 

Age,  from  thirty  to  forty-five ; 

Sterility ; 

Menstrual  disorders  of  long  standing. 
Concerning  the  exciting  causes,  one  writing  in  the  year  1874 
may,  unfortunately,  quote  the  words  of  Sir  Charles  Clarke,  recorded 
in  1814:  "Nothing  is  known  respecting  the  cause  of  this  disease." 
Sixty  years  of  research  have  thrown  no  light  upon  its  etiology. 


504  FIBEOID    TUMOES    OF    THE    UTERUS. 

Complications. — Tlie  most  frequent  of  the  complicatious  which 
show  themselves  in  the  course  of  the  disease  are — 

Endometritis; 

Displacement; 

Cystitis; 

Ohstruction  of  the  rectum ; 

Hemorrhoids ; 

Pelvic  peritonitis ; 

Areolar  hyperplasia; 

Atrophy  of  uterine  walls.   • 

Every  one  who  has  made  autopsies  upon  cases,  in  which  uterine 
fibroids  have  existed,  must  have  been  struck  by  the  fact  of  the 
varied  appearance  of  the  walls  of  the  uterus.  Where  several 
tumors  exist  the  uterine  cavity  is  sometimes  so  perverted  and 
rendered  so  tortuous  that  it  cannot  be  traced,  while  in  cases  wliore 
a  large  number  of  tumors  are  formed,  the  whole  uterus  seems  to 
have  disappeared,  its  place  being  usurped  by  tumors.  In  the  case 
already  cited,  in  which  I  counted  thirty-live  tumors,  no  trace  of 
the  uterus  could  be  discovered  by  the  naked  eye,  above  the  os 
internum.  In  some  cases  the  vice  of  nutrition  set  up  by  the  pre- 
sence of  these  growths  results  in  thickening  of  the  uterine  walls  by 
the  establishment  of  interstitial  hypertrophy,  in  others  localized 
points  of  thickening  exist,  while  in  others  still,  the  wall  of  the 
uterus  may  become  so  attenuated  by  distention  and  atrophy  as  to 
leave  only  a  thin  film  to  represent  it.  This  distended  and  attenu- 
ated organ  is  that  which  Walter  has  styled  the  "  membranous 
uterus." 

Symptoms. — This  enumeration  of  complications  is  a  sufficient 
explanation  of  the  great  number  of  rational  signs  which  present 
themselves,  for  not  only  do  we  meet  with  the  symptoms  of  fibroid 
tumors,  but  with  those  of  a  variety  of  disorders  which  they  excite. 
Most  prominent  among  the  symptoms  are — 

Menorrhagia  or  metrorrhagia ; 

Irritability  of  bladder  and  rectum; 

Pain  throughout  the  pelvis  ; 

Uterine  tenesmus ; 

Profuse  leucorrhoea; 

Dysmenorrhoea ; 

Signs  of  pressure  on  crural  nerves  and  vessels ; 

Watery  discharge  from  uterus. 

These  symptoms  are  not  equally  common  to  the  three  varieties 


PHYSICAL    SIGNS.  505 

of  the  affection.  Subperitoneal  tumors  often,  and  interstitial 
tumors  sometimes,  are  accompanied  by  none,  or  at  least  by  very 
few  of  tliem.  It  is  tlie  submucous  variety  which  most  constantly 
and  prominently  develops  them. 

Physical  Signs. — Although  the  rational  signs  are  so  numerous 
and  striking,  they  can  never  do  more  than  excite  a  suspicion, 
which  leads  to  investigation  by  physical  means. 

In  the  case  of  a  large  tumor  no  difficulty  in  diagnosis  will  pre- 
sent itself;  for  the  results  of  vaginal  touch,  abdominal  palpation, 
and  conjoined  manipulation  will  be  so  decided  as  to  settle  the 
character  of  the  case  definitively.  When,  however,  a  growth  of 
small  size  exists,  great  difficulties  will  often  attend  diagnosis, 
which  may  be  delayed  until  the  case  has  been  under  observation 
for  a  lone;  time.  A  thorouo-h  examination  involves  full  and  careful 
exploration,  by  touch,  of  the  anterior  and  posterior  surfaces  of  the 
uterus,  as  well  as  of  its  cavity  to  the  fundus. 

To  examine  the  external  surfaces  of  the  uterus,  the  patient  should 
lie  upon  the  back  with  the  thighs  flexed.  All  constriction  should 
be  removed  from  the  waist,  and  the  bladder  and  rectum  emptied. 
The  examiner  then,  depressing  the  uterus  by  the  right  hand  placed 
over  the  liypogastrium,  should  sweep  the  index  finger  of  the  other 
as  high  up  as  possible  over  the  posterior  wall,  first  by  vaginal  and 
then  by  rectal  touch.  While  the  finger  in  the  vagina  or  rectum 
lifts  the  uterus,  tlie  tips  of  the  fingers  placed  on  the  abdomen  should 
be  forced  behind  the  fundus,  and  downwards  over  the  posterior 
uterine  wall  so  as  to  approach  the  finger  within  the  pelvis,  ^y 
these  means  the  posterior  wall  will  be  superficially  examined  in 
women  with  tense  abdominal  muscles,  thoroughly  in  those  in  whom 
they  are  thin  and  relaxed. 

The  finger  in  the  vagina  now  drawing  the  cervix  forwards,  the 
fingers  of  the  hand  on  the  abdomen  should  be  made  to  depress  its 
walls  so  as  to  sweep  from  the  fundus  over  the  anterior  surface 
down  to  the  cervix.  The  finger  under  the  cervix  lifting  it  up  will 
oflfer  itself  as  an  opposing  force  to  the  hand  on  the  abdomen.  This 
manoeuvre  will  fully  expose  to  examination  the  anterior  surface  of 
the  uterus,  unless  the  patient  be  very  fat.  Should  she  be  so,  a  tena- 
culum may  be  fastened  in  the  cervix,  and  the  uterus  drawn  down 
by  it  so  that  the  posterior  wall  will  be  better  within  reach  of  rectal 
touch,  and  the  anterior  wall  of  vaginal  exploration  when  the  finger 
is  pressed  firmly  against  the  base  of  the  bladder. 

AVhen,  in  a  case  in  which  it  is  of  importance  that  a  certain  diag- 
nosis should  be  arrived  at,  it  proves  impossible  to  do  so  by  use  of 


506  FIBEOID    TUMORS    OF    THE    UTERUS. 

the  means  thus  far  mentioned,  Simons's  method  may  be  resorted  to 
with  great  confidence  as  to  the  results  which  it  will  yield. 

For  investigating  the  interior  surface  of  the  uterus,  the  neck 
should  be  fully  dilated  by  tents  of  sponge  or  sea-tangle,  and  im- 
mediately upon  their  removal,  the  uterus  being  depressed  as  for 
examination  of  tlie  outer  surfixce,  the  finger  should  be  carried  up 
to  the  fundus. 

Differentiation.— The  diseases  which  may  be  confounded  with 
fibrous  tumors  are — ■ 

Pregnancy ; 

Periuterine  cellulitis  or  abscess; 

Pelvic  hematocele; 

Anteflexion  or  retroflexion ; 

Ovarian  tumors ; 

Fecal  impaction. 
In  pregnancy  amenorrhoca  and  other  signs  of  utero-gestation 
exist,  while  in  uterine  fibroids  there  is  usually  a  tendency  to  men- 
orrhagia.  In  pregnancy  the  uterus  is  symmetrical,  in  fibroids 
usually  asymmetrical.  The  tumor  found  in  pregnancy  is  generally 
softer  than  that  in  fibroids  and  more  uniformly  median  in  position. 
In  a  doubtful  case  time,  with  its  development  of  foetal  movements, 
will  always  settle  the  point. 

The  tumor  created  by  cellulitis  is  usually  immovable,  very 
sensitive,  accompanied  by  fever,  comes  on  suddenly,  and  fixes  the 
uterus.     A  fibroid  tumor  is  the  opposite  of  this  in  every  respect. 

Hematocele  generally  occurs  suddenly  and  with  violent  symp- 
toms. The  tumor  is  sensitive  and  immoval)le,  at  first  semi-fluid, 
and  accompanied  by  tympanites  and  constitutional  disturbance. 
Fibroid  tumors  show  no  such  symptoms. 

Flexion  may  be  determined  by  the  uterine  probe,  and  differen- 
tiation established  between  it  and  fibroids  by  conjoined  manipula- 
tion and  rectal  touch. 

Ovarian  tumors  of  solid  form  are  the  only  ones  which  usually 
give  difficulty  in  diagnosis,  and  these  are  rare.  They  are  unaccom- 
panied by  menorrhagia,  can  be  pushed  from  side  to  side  without 
affecting  the  position  of  the  uterus  as  ascertained  by  vaginal  touch, 
and  are  less  affected  by  movement  of  the  uterus  by  means  of  the 
uterine  sound.  In  cases  where  an  ovarian  tumor  is  firmly  attached 
to  the  uterus,  differentiation  is  not  only  difficult  but  often 
impossible. 

Fecal  impaction  presents  a  tumor  which  can  often  be  indented  by 
pressure,  is  generally  in  the  caput  coli,  does  not  move  with  the 


COURSE,   DURATION,   AND    TERMINATION.  507 

uterus,  gives  severe  intestinal  pain  and  disorder,  and  exerts  little 
influence  on  the  functions  of  the  uterus. 

From  this  rapid  disposal  of  the  subject  of  differentiation  it  must 
not  be  supposed  that  it  is  always  an  easy  matter.  In  many  cases 
only  careful  watching  will  enable  the  diagnostician  to  arrive  at  a 
certain  conclusion. 

Prognosis. — The  practitioner  cannot  be  too  cautious  or  display 
too  much  reticence  in  pronouncing  the  prognosis  of  uterine  fibroids. 
There  are  few  diseases  in  which  the  young  physician  will  be  led 
into  greater  error  or  be  made  to  regret  more  decidedly  an  over- 
confident prediction.  Fibroid  tumors,  unless  of  great  size,  rarely 
end  fatally,  however  gloomy  the  prospect  may  appear  when  they 
are  first  discovered.  And  yet  death  from  them  is  not  so  infrequent 
as  to  warrant  an  entirely  favorable  prognosis. 

Frequency. — These  statements  are  to  a  certain  degree  corrobo- 
rated by  an  examination  into  their  frequency,  "Were  they  as  dan- 
gerous as  is  sometimes  supposed,  a  large  number  of  deaths  would 
be  annually  produced  by  them,  for,  to  use  the  words  of  McClintock, 
"  without  question  the  most  frequent  organic  disease  of  the  uterus, 
if  we  except  inflammation  and  its  eflfects,  is  fibrous  tumor,"  Bayle 
estimated  that  of  all  women  dying  beyond  thirty-five  years  of  age, 
twenty  per  cent,  were  thus  aftected.  Even  supposing  that  his 
assumption  was  an  exaggerated  one,  an  idea  of  the  frequency  of  the 
affection  may  be  gathered  from  the  fact  of  his  venturing  upon  it, 
and  surprise  at  it  will  be  modified  when  the  following  extract  is 
read  from  Klob,^  In  speaking  of  their  frequency,  he  says,  "  At  the 
climacteric  period,  it  is  such  that  undoubtedly  40  per  cent,  of  the 
uteri  of  females,  who  die  after  the  fiftieth  year,  contain  fibroid 
tumors." 

Let  the  diagnostician  who  has  discovered  a  uterine  fibroid,  and 
feels  prompted  to  give  a  grave  prognosis  concerning  it,  bear  these 
facts  in  mind,  and  he  may  be  prevented  from  injuring  his  patient's 
comfort  and  his  own  reputation. 

Course.,  Duration^  and  Termination. — As  already  stated,  these 
growths  may  attain  the  enormous  weight  of  fifty  pounds.  Fortu- 
nately they  very  rarely  reach  such  dimensions,  but  even  when 
they  do  not,  they  sometimes  exhaust  the  patient  by  metrorrhagia, 
leucorrhoea,  hydrorrhoea,  and  a  low  grade  of  constitutional  irrita- 
tion, often  attended  by  hectic  fever.  But  this  termination,  like 
the  preceding,  is  exceptional.     Having  attained  a  moderate  size 

Op.  cit.,  p.  177. 


608  FIBROID    TUMOES    OF    THE    UTERUS. 

they  generally  remain  stationary,  or  increase  slowly  until  the 
menopause,  creating  considerable  inconvenience  and  depreciating 
the  patient's  strength  by  hemorrhage.  Then  undergoing  a  certain 
degree  of  atrophy  with  the  cessation  of  uterine  and  ovarian  func- 
tions, they  cease  to  be,  to  any  great  degree,  a  source  of  annoyance, 
or  at  least  of  danger.  Even  during  the  age  of  uterine  activity, 
nature  may,  unaided,  effect  a  cure  by  the  following  means ; 

Absorption  or  atrophy ; 

Direct  expulsion  by  rupture  of  attachment ; 

Sloughing,  from  deprivation  of  nutrition,  or  inflammation; 

Calcareous  degeneration ; 

Gangrene. 

The  tumor  is  sometimes  deprived  of  nutrition  by  inflammatory 
action  occurring  in  the  vascular  structure  of  the  uterine  attach- 
ment, which  has  already  been  described,  collections  of  pus  being 
sometimes  discovered  in  it. 

Throughout  their  existence  these  tumors  sympathize  in  the 
uterine  changes  which  attend  upon  these  three  conditions;  men- 
struation, utero-gestation,  and  the  menopause.  With  the  occur- 
rence of  menstruation  they,  like  the  tissue  of  the  uterus,  become 
congested,  enlarged,  and  sensitive.  During  pregnancy  their  com- 
ponent muscular  fibres  grow,  and  probably  undergo  retrograde 
metamorphosis  after  delivery.  As  senile  atrophy  succeeds  the 
menopause,  their  nutrition  is  impaired,  and  fatty  and  calcareous 
degeneration  sometimes  occur. 

Sometimes  fluid  collections  take  place  within  these  masses,  some 
morbid  process  destroying  their  tissue  as  if  by  liquefaction.  The 
fluid  thus  collecting  may  be  purulent,  watery,  or  sanguineous.  In 
some  cases  a  colloid  degeneration  is  said  by  pathologists  to  occur 
in  or  near  the  centre  of  the  mass,  which  softens  down  and  liquefies 
the  fibroid  tissue.  In  others,  an  apoplexy  takes  place,  which  creates 
the  initial  cavity,  and  this  is  subsequently  found  filled  with  the 
debris  of  the  clot  and  with  turbid  serum. 

Palliative  Treatment. — In  the  vast  majority  of  cases  of  interstitial 
and  subserous  variety,  the  eftbrts  of  the  practitioner  should  be 
limited  to  palliation  of  the  evils  resulting  from  these  growths. 
These  evils  will  generally  be  due  to  either  one  or  all  of  the  three 
following  conditions  which  result  from  them :  displacement  of  the 
uterus,  pressure  on  surrounding  organs  and  parts,  and  menorrhagia 
or  metrorrhagia.  The  first  will  often  be  greatly  relieved  by  resti- 
tution of  the  displaced  organ,  and  its  retention  at,  or  even  above, 


PALLIATIVE    TREATMEXT.  509 

the  superior  strait.  This  niaj  be  accomplished  by  the  ordinary 
means  of  replacement,  and  the  use  of  the  bulb  pessary  (Fig.  Ill), 
in  difficult  cases,  or  of  one  of  the  varieties  of  intra-vaginal,  ante- 
version,  or  retroversion  pessaries,  in  less  obstinate  ones.  By  a 
properly  adjusted  pessary,  aided  by  complete  removal  of  weight 
and  constriction  from  the  abdomen,  and  the  use  of  an  efficient 
abdominal  pad,  the  second  set  of  evils  may  be  ameliorated.  Relief 
of  the  third  generally  proves  difficult,  and  not  rarely  impossible. 
The  presence  of  the  fibroid  in  utero  keeps  up  congestion  of  the 
endometrium,  and  this  results  in  leucorrhoea,  hydrorrho^a,  and 
menorrhagia.  Fortunately,  good  can  generally  be,  to  a  limited 
extent,  at  least,  eflfected  by  rest  in  the  recumbent  posture  during 
the  menstrual  periods ;  the  use  of  hemostatic  agents,  as  elixir  of 
vitriol,  ergot,  tincture  of  cannabis  indica,  gallic  acid,  etc.;  and  the 
use  of  the  tampon  after  a  sufficient  loss  has  occurred  to  meet  the 
demands  of  ovulation.  The  practice  of  applying  a  tampon  of  cotton 
impregnated  with  solution  of  alum  after  a  menorrhagic  flow  has, 
under  these  circumstances,  lasted  for  four  or  five  days,  I  often  resort 
to,  and  never  with  any  but  good  results.  Without  some  such 
controlling  influence,  the  patient  will  sometimes  become  greatly 
exsanguinated.  While  these  means  are  being  adopted  the  bowels 
should  be  kept  regular,  and  the  functions  of  the  skin  and  liver 
carefully  supervised. 

In  some  cases  the  engorged  condition  of  the  mucous  membrane 
lining  the  uterus  and  covering  the  tumor  causes  it  to  become 
covered  by  little  fungoid  growths,  which  keep  up  and  greatly 
increase  the  amount  of  hemorrhage.  Under  these  circumstances, 
the  application  of  the  curette  is  of  great  service.  Even  if  there 
should  be  an  error  in  diagnosis,  this  treatment  will  accomplish 
good  by  severing  the  vessels  of  the  mucous  membrane,  and  relieving 
congestion. 

If  these  means  fail,  as  they  often  will  do,  more  effiactual  ones 
must  be  adopted.  The  cervix  should  be  dilated  by  tents,  and  the 
uterine  cavity  thoroughly  washed  over  by  an  injection  of  equal 
parts  of  tincture  of  iodine  and  water,  or  solution  of  persulphate 
of  iron,  one  part  to  ten  of  water. 

Should  it  be  found  that  by  this  means  even,  hemorrhage  is  not 
sufficiently  controlled,  resort  should  be  promptly  had  to  palliative 
resources  of  a  surgical  character.  These  may  prove  efficient  as 
hemostatics,  while  at  the  same  time  they  prepare  the  way  for 
curative  means,  if  they  should  be  in  time  deemed  necessary. 

It  has  been  found  that  hemorrhage  due  to  uterine  fibroids  is 


510  FIBROID    TUMOES    OF    THE    UTEEUS. 

often  greatly  diminislied  by  section  of  the  uterine  neck,  a  practice 
which  was  tirst  inaugurated  by  Amussat,  and  imitated  by  N'elaton, 
Brown,  and  McClintock.  In  some  not  very  explicable  manner, 
cutting  through  the  cervical  canal  by  deep  incisions  on  its  sides 
exerts  a  good  influence  in  controlling  this  form  of  hemorrhage.  A 
still  more  powerful  eflect  will  follow  incision  directly  through  the 
investing  coat  of  the  tumor  itself,  so  as  to  cut  its  capsule,  its 
superficial  layer  of  fibres,  and  its  superficial  bloodvessels,  and  thus 
diminish  its  vascular  supply. 

Curative  Means. — Within  the  last  quarter  of  a  centuiy  we  have 
rapidly  advanced  in  our  surgical  resources  for  the  cure  of  uterine 
fibroids.  They  are  not  even  now,  however,  of  such  a  character  as 
to  warrant  a  resort  to  them,  when  by  other  means  we  can  avoid 
the  dangers  which  attach  to  them.  For  this  reason  it  may  be 
stated  that  surgical  procedures  should  be  resorted  to  only  under 
two  circumstances :  1st,  where  the  growth  is  so  located  as  to  render 
removal  practicable  and  safe ;  2d,  where  the  disease  is  threatening 
the  patient's  life.  In  the  removal  of  these  growths  the  practitioner 
imitates,  to  a  certain  extent,  the  processes  by  which  nature  accom- 
plishes a  cure.  Bringing  to  his  aid  some  of  her  methods  which 
have  been  mentioned,  he  adds  to  them  others  which  she  never 
develops. 

Uterine  fibroids,  whether  submucous,  subperitoneal,  or  intersti- 
tial, may  be  removed  by  one  of  the  following  means : 

Absorption ; 

Excision,  ecrasement,  and  galvano-cautery  ; 

Avulsion ; 

Enucleation ; 

Gastrotomy. 

Absorption. — "Whether  their  absorption  can  be  excited  by  any  of 
those  medicines  styled  absorbents,  is  not  certainly  ascertained. 
Tumors  have  in  some  instances  been  known  to  disappear  while  such 
drugs  have  been  employed,  and  perhaps  they  did  so  in  consequence 
of  their  use.  But  no  such  efiect  can  be  looked  for  with  any  con- 
fidence. Indeed,  with  our  present  experience,  such  a  result  must  be 
regarded  as  decidedly  exceptional.  Scanzoni,  after  advising  those 
medicines  which  are  most  popular  as  stimulants  of  absorj)tion,  says, 
"  "We  do  not  remember  a  single  case  in  which,  with  the  means  in- 
dicated, or  with  others,  we  have  obtained  the  complete  cure  of  a 
fibrous  body."  If  such  drugs  be  tried  for  this  purpose  they  should 
be  continued  for  many  months,  and  even  a  year  or  two,  before  the 


ABSORPTION.  511 

trial  can  be  considered  fairly  made,  for  tlieir  action  is  never  imme- 
diate. Those  in  greatest  esteem  are  iodine,  the  iodide  and  bromide 
of  potassium ;  that  class  of  drugs  supposed  to  possess  the  power  of 
inducing  fatty  degeneration,  as  arsenic,  phosphorus,  and  lead, 
"  steatogenic"  drugs,  as  they  have  been  styled ;  preparations  of 
lime ;  and  the  waters  of  certain  mineral  spjrings,  as  Kreuznach, 
Kissingen,  Krankenheil,  etc.  Some  of  these  may  be  employed 
externally  in  the  form  of  hip-baths  as  well  as  internally. 

About  two  years  ago,  a  series  of  nine  cases  of  uterine  fibroids 
was  published  by  Hildebrandt,^  of  Konigsberg,  in  which  the  only 
treatment  adopted  consisted  in  the  subcutaneous  injection  of  ergot. 
In  seven,  an  extraordinary  improvement  took  place.  The  theory 
of  the  plan  is  this :  compression  of  the  tumor  by  ergotic  contrac- 
tion of  uterine  fibre  interferes  with  nutrition;  fatty  degeneration 
in  consequence  occurs  ;  and  the  tumor  is  thus  rendered  susceptible 
of  absorption.  The  results  obtained  by  Hildebrandt  are  so  favor- 
able, that  the  most  sanguine  must  be  led  to  fear  that  future  experi- 
ence may  not  prove  as  successful.  His  method  has,  however,  even 
now  been  so  far  tested  by  others  that  it  must  be  conceded  that  it 
promises  better  results  than  any  other  which  has  been  employed. 

The  following  is  a  condensed  synopsis  of  some  of  Hildebrandt's 
cases : 

Case  1.  Patient  set.  31 ;  tumor  for  three  years  ;  uterus  as  large  as  at 
seventh  month  of  pregnancy ;  hemorrhages  frequent  and  copious.  In- 
jections of  ergotine  practised  daily  for  six  weeks,  when  menses  became 
regular  and  painless.  Injections  continued  daily  for  fifteen  weeks  more, 
when  tumor,  which  had  been  growing  smaller  from  week  to  week,  was 
found  to  have  disappeared. 

Case  2.  Under  use  of  injections  uterus  "  diminished  in  volume  by 
absorption  of  the  Intra-uterine  tumor;  menstruation  became  regular;  and 
pain  and  leucorrhoea  disappeared." 

Case  3.  Patient  aet.  30 ;  profuse  sanguineous  discharges,  sometimes 
lasting  from  six  to  eight  months,  since  the  age  of  sixteen.  Anaemia  and 
emaciation  extreme  ;  fundus  of  uterus  nearly  midway  between  pubis  and 
umbilicus;  by  touch,  tumor  distinguished  in  the  anterior  wall  of  uterus. 
Subcutaneous  injections  daily  from  January'  ITth  to  March  5th,  when  the 
patient  was  discharged  ;  menses  regular ;  general  condition  improved  ; 
and  uterus  notably  diminished  in  size ;  the  vaginal  portion  having  in 
great  part  returned  to  its  normal  volume. 

Case  6.  Patient  aet.  45  ;  uterus  reached  to  umbilicus ;  anteverted ; 
large  fibroid  in  anterior  wall ;  hemorrhage  ;  and  Irregular  menses.    After 

'  Berlin,  Kliii.  Woch.     Amer.  Journ.  Obstet.,  Nov.  1872. 


512  FIBROID    TUMORS    OF    THE    UTERUS. 

resort  to  injections,  improvement  was  well  marked  ;  fundus  descending 
to  a  point  raidwa^^  between  umbilicus  and  pubes. 

The  solution  used  by  the  hypodermic  syringe  consisted  of  three 
parts  of  the  aqueous  extract  of  ergot  to  seven  and  a  half  of  gly- 
cerine and  the  same  of  water.  The  point  of  puncture  was  the 
hypogastric  region.  At  each  injection  three  grains  of  the  extract 
were  used. 

In  some  cases  this  treatment  produces  severe  ergotism  at  so  earl}^ 
a  period  that  it  has  to  be  desisted  from,  while  at  others  it  results 
in  the  production  of  small  abscesses  of  painful  character.  Hilde- 
brandt  declares  that  the  introduction  of  the  needle  straight  down 
into  the  subcutaneous  areolar  tissue  obviates  the  occurrence  of 
abscesses.  Should  the  subcutaneous  method  disagree  with  the 
patient,  as  it  did  in  two  out  of  Hildebrandt's  nine  cases,  ergot 
may  be  given  by  mouth  or  rectum,  with  the  prospect  of  exciting 
tonic  uterine  contraction,  diminishing  vascularity,  and  lessening 
sanguineous  and  mucous  discharges,  and  subsequent  growth  of  the 
tumor. 

Since  the  publication  of  Hildebrandt's  method  I  have  adopted 
it  in  a  number  of  cases,  and  while  I  cannot  claim  such  results  as 
he  obtained,  I  am  prepared  to  endorse  it  as  one  very  promising  of 
excellent  results. 

Surgical  Procedures. — The  two  elements  which  govern  success  in 
the  removal  of  these  growths  by  the  surgical  processes  which  now 
come  to  be  considered  are  these:  1st,  the  degree  of  projection  of 
the  tumor  into  the  uterine  cavity ;  2d,  the  degree  of  dilatation  of 
the  cervical  canal.  I  do  not  say  that  they  decide  the  propriety  of 
operation.  Removal  may  possibly  be  practised  where  the  tumor 
is  to  a  great  extent  interstitial,  only  causing  slight  protrusion 
inwards  of  the  mucous  membrane,  and  where  the  cervical  canal  is 
completely  contracted.  But  in  such  cases  it  is  more  difficult  of 
accomplishment,  and  much  more  dangerous  to  the  life  of  the 
patient.  An  interstitial  fibroid  excites  uterine  contractions,  which 
in  time  usually  extrude  it,  making  it  either  subserous  or  sub- 
mucous. In  both  cases  it  carries  with  it  a  covering  of  uterine 
tissue,  which  when  it  enters  the  uterine  cavity  is  one  of  the  influ- 
ences which  prevent  its  expulsion  into  the  vagina;  the  closure 
of  the  cervix  being  another.  In  some  cases  nature  unaided  over- 
comes these  obstacles.  When  they  are  too  powerful  for  her,  art 
comes  to  her  aid  and  removes  them  for  her. 

Before  all  the  operations  practised  for  removal  of  fibroids  from 


REMOVAL. 


513 


the  cavity  of  the  uterus,  the  cervix  must  be  fully  dilated.  This 
may  be  accomplished  by  three  methods : 

1st.  The  cervix  may  be  gradually  dilated,  the  attachments  of  the 
tumor  broken  little  by  little,  and  extrusion  slowly  effected  by  ergot. 

2d.  The  cervix  may  be  rapidly  dilated  in  part  before  the  opera- 
tion, and  in  part  at  the  moment  of  practising  it. 

3d.  The  cervix  may  be  gradually  and  fully  dilated  before  surgi^ 
cal  interference  is  established. 

By  the  first  plan  the  cervix  is  dilated  by  tents,  its  vaginal  portion 
cut  by  scissors  up  to  the  vaginal  junction,  the  fibres  of  the  canal 
making  the  os  internum  severed  laterally  by  a  delicate  knife, 
hemorrhage  arrested  by  tampon,  and  ergot  given  to  cause  expulsion 
of  the  tumor  and  increase  cervical  expansion.  As  these  preparatory 
measures  usually  control  hemorrhage,  further  interference  may  be 
indefinitely  delayed.  Meantime  ergot  is  steadily  given,  and  when- 
ever the  attachment  of  the  growth  to  the  uterus  can  be  reached, 
it  is  severed  by  the  finger  or  a  blunt  instrument. 

By  the  second  plan  the  cervix  is  dilated  by  tents,  and  cut  as 
above  mentioned  at  the  moment  of  operation. 

By  the  third  it  is  fully  dilated  by  tents,  or  slit  by  scissors  and 
knife,  and  dilatation  secured  and  increased  by  use  of  water  bags 
until  time  of  operation,  which  is  not  long  delayed.  The  ordinary 
water  bags  known  as  Barnes's  dilators  are  not  powerful  enough  for 
the  expansion  of  the  cervix  of  the  non-puerperal  uterus,  and  be- 
sides this  they  dilate  irregularly.     Molesworth's  dilator,  shown  in 


Fig.  143. 


Molesworth's  cervical  dilator. 

Fig.  143,  is  by  far  more  efficient  in  these  cases.  This  instrument 
consists  of  a  series  of  long  bags  of  pure  rubber,  constructed  in  such 
a  manner  as  to  secure  lateral  expansion  without  elongation,  and  a 
nickel-plated  force  pump,  worked  by  screw  power,  by  which  water 
or  air  can  be  forced  into  the  bag,  to  dilate  it  as  rapidly  or  as  slowly 
as  desired.  Each  instrument  has  a  small  stopcock,  enabling  the 
33 


514 


FIBROID    TUMORS    OF    THE    UTERUS. 


operator,  if  be  desire,  to  remove  the  pump,  leaving  tlie  bag  in 
position,  and  tims  continue  bis  dilatation  for  any  lengtb  of  time. 

Each  instrument  bas  two  bags,  the  smaller  is  one-eighth  of  an 
inch  in  diameter,  and  capable  of  being  dilated  to  from  one-half  to 
three-fourths  of  an  incli.  The  larger  bag  is  one-fourth  of  an  inch, 
and  can  be  dilated  to  from  one  to  one  and  a  half  inches. 

Excision. — Should  a  small  submucous  fibroid  project  into  the 
uterine  cavity,  it  may  be  removed  by  the  severance  of  its  attach- 
ment, by  means  of  the  knife,  scissors,  or  other  cutting  instrument. 
If  it  be  within  reach  of  the  knife  or  scissors  it  may  be  removed  by 
them.  In  case  it  be  attached  higlier  in  the  uterine  cavity,  the  polyp- 
tome  of  Aveling  may  be  made  to  answer  a  good  purpose  (Fig.  144). 

Fiff.  144. 


Avcling's  polyptoiiH'. 

Removal  may  likewise  be  accomplished  by  the  forceps  of  ITdlaton, 
represented  in  Fig.  14o,  or  by  long-handled,  curved  scissors,  by 
which  as  much  as  can  be  got  within  their  blades  should  be  cut 
away.  In  this  way,  piece  by  piece,  a  large  portion  or  the  whole  of 
the  growth  may  be  excised. 

Fig.  145. 


Nelaton's  forceps. 


JEcrasement — In  many  cases  in  which  excision  may  be  practised, 
^crasement  becomes  possible  and  should  be  preferred.  The  opera- : 
tion  consists  in  cutting  off  the  mass,  as  near  its  attachment  as.] 
possible,  by  the  ecraseur.  This  instrument,  the  invention  of  M.| 
Chassaignac,  of  Paris,  consists  of  a  flattened  tube  of  steel  which; 
has  two  rods  of  the  same  metal  passing  through  it  to  its  upper 
extremity  (Fig.  146).  To  the  end  of  each  of  these  the  extremity) 
of  a  chain  is  attached.  This  is  passed  around  the  part  to  be  cut 
off,  and  the  rods  are  retracted  b}'-  a  ratchet  movement  at  the  other 
extremity.      Steadily  and  slowly  the  chain  tightens  around  the 


ECRASEMENT. 


515 


mass  and  cuts  its  way  through  it.  The  dcraseur  not  only  presents 
the  great  advantage  of  preventing  hemorrhage,  but  experience 
proves  that  after  its  use  inflammatory  action  is  much  less  likely  to 
occur  than  after  that  of  cutting  instruments.     Should  the  tumor  be 

Fig.  146. 


The  ecraseur,  striiiglit  and  curved. 

small  and  have  passed  out  of  the  uterus  into  the  vagina,  the  chain 
of  the  ecraseur  may  be  passed  over  it  as  a  noose,  by  the  fingers. 
If  it  be  small  and  inside  the  uterus,  or  if  the  tumor  be  of  great  size, 
whether  in  the  vagina  or  uterus,  it  may  be  necessary  first  to  pass 
a  cord  around  it  by  means  of  canul?e,  and  in  this  way  to  draw  in 
place  the  chain,  which  may  be  subsequently  attached  to  the  ecraseur. 

In  many  cases  the  use  of  the  Ecra- 
seur is  so  difficult  that  it  becomes  Fig.  147. 
inefiectual.  Under  these  circum- 
stances the  wire  rope  ecraseur  of  Dr. 
Braxton  Hicks  answers  a  most  excel- 
lent purpose.  Its  contracting  wire  is 
stiff",  small,  and  manageable,  and  thus 
we  may  be  able  to  ensnare  a  tumor 
^vhicll  was  unattainable  by  Chassaig- 
nac's  instrument. 

Should  the  tumor  be  very  large  and 
fill  the  vagina  completely,  there  are 
Two  methods  by  which  it  may  be 
entirely  removed:  1st,  it  may  be 
drawn  down  by  obstetric  forceps  and 
delivered;  2d,  it  may  be  cut  away, 
liiece  by  piece,  until  its  base  be 
reached.  By  the  first  plan  the  uterus 
is  temporarily  inverted,  the  morbid 
growth  removed  by  the  knife,  scissors, 
galvano-cautery,  or  ecraseur,  and  the  uterus   replaced,  after  the 


The  ecraseur  at  work. 


516  FIBROID    TUMORS    OF    THE    UTERUS. 

stump,  should  it  bleed,  has  been  seared  by  the  white-hot  iron. 
This  process  was  first  advised  and  practised  hy  Desault  and  Herbi- 
neaux.  The  second  plan  is  best  carried  out  by  the  aid  of  the 
galvano-cautery  or  ecraseur.  As  much  of  the  tumor  as  can  be 
secured  is  seized  in  the  wire  or  chain  and  removed.  Then  another 
portion  is  engaged,  and  so  on  until  a  great  part  or  the  whole  of  the 
mass  is  cut  away. 

Avulsion. — The  cervix  being  dilated  the  tumor  is  seized  by  Vul- 
sellum  forceps  and  firm  traction,  with  sliglit  rotatory  movement, 
made  upon  it.  Under  this  tractile  force  its  uterine  attachments  i| 
may  be  ruptured  and  the  tumor  come  away.  If  it  do  not  do  so, 
the  operator  passes  one  hand  into  the  vagina  and  two  fingers  into  i| 
the  uterus,  by  which  he  ruptures  the  attachments  of  the  growth 
and  thus  frees  it.  Meantime  the  hand  of  an  assistant  is  placed  I 
over  the  hypogastrium  to  steady  and  depress  the  uterus.  Dr.  West,^ 
writing  in  1864,  says,  "  the  forcible  avulsion  of  polypi  is  a  rough 
and  hazardous  proceeding,  a  relic  of  barbarous  surgery."  Of  late  i 
Dr.  Duncan  has  ably  advocated  this  excellent  method,  against  which 
I  feel  that  Dr.  West  inveighed  too  strongly. 

Enucleation. — Where  the  attachments  of  the  tumor  are  so  exteii^ 
sive,  01*  where  it  is  so  much  embedded  in  the  uterine  parenchyma, 
as  to  render  it  impossible  to  practise  upon  it  any  of  the  procedures 
already  described,  the  operation  of  enucleation  ofters  itself  as  a  mostj 
efficient  and  valuable  resource.  It  has  been  stated  that  the  attach 
ment  of  submucous  and  even  interstitial  fibroids  to  the  uterine 
wall  is  not  firm,  they  being  surrounded  by  a  layer  of  loose  cellular 
tissue.  This  fact  suggested  many  years  ago,  to  the  mind  of  Vel- 
peau,  the  possibility  of  enucleating  them,  and  in  1840,  M.  Amussat 
put  the  theory  into  practice.  Since  that  time  the  operation  has 
been  resorted  to  by  many  surgeons,  among  the  most  successful  of 
whom  may  be  mentioned  Dr.  Atlee,  of  Philadelphia.  At  the  same 
time  that  it  must  be  regarded  as  an  invaluable  resource  in  many 
difficult  cases,  it  cannot  be  denied  that  it  is  one  attended  by  great 
hazard,  as  it  may  be  destructive  to  life  by  inducing  exhaustion, 
hemorrhage,  perforation  of  the  uterus,  pysBmia,  or  inflammation  of 
the  pelvic  viscera.  Dr.  West  reports  twenty-eight  cases  in  which 
it  was  performed,  fourteen  of  which  proved  fatal. 

"  Peritonitis,  phlebitis,  and  pysemia,"  says  Dr.  West,'  in  esti- 
mating the  prospects  of  success  held  out  by  enucleation,  "the 
consequences  of  violence  done  to  the  uterus  of  women  exhausted 


'  Op.  cit.,  Eng.  ed.,  p.  305. 


ENUCLEATION.  517 

by  large  and  frequently  repeated  floodings,  are  dangers  from  which 
but  few  have  altogether  escaped ;  under  which  I  fear  that  correct 
statistics  will  show  that  most  have  succumbed."  The  dangers  at- 
tending its  performance  should  not  deter  the  surgeon  from  resort 
to  it  in  suitable  cases  which  absolutely  require  aid.  They  should 
merely  induce  him  to  exhaust  all  palliative  means  before  resort- 
ing to  this,  which  should  be  looked  upon,  in  large  tumors,  as  a 
last  resource.  I  have  by  this  method  and  avulsion  removed  seven 
tumors,  varying  in  size  from  a  hen's  egg  to  that  of  a  goose,  and  all 
my  patients  have  recovered.  Two  others,  however,  have  died  from 
efforts  at  dilatation  of  the  cervix  preparatory  to  this  procedure. 

Enucleation  may  be  practised  by  two  methods:  immediate,  in 

which  the  tingers  of  the  operator  at  one  sitting  accomjilish   the 

removal  of  the  tumor;  and  gradual,  in  which  the  fingers  of  the 

j    operator  merely  inaugurate  the  process  which  contractions  of  the 

uterus  are  excited  to  complete. 

If  the  first  plan  is  to  be  pursued  the  patient,  after  previous  com- 
plete dilatation  of  the  cervical  canal,  is  placed  ujDon  her  back  upon 
a  strong  table,  the  legs  being  held  by  assistants.  An  assistant 
firmly  depresses  the  uterus  by  pressure  on  the  abdomen,  and  the 
operator,  by  means  of  a  pair  of  scissors,  guided  by  two  fingers,  cuts 
into  the  capsule.  Into  this  opening  he  passes  the  index  finger  and 
fixes  the  tumor.  By  means  of  scissors  or  a  probe-pointed  bistoury 
a  crucial  incision  is  then  made  through  the  capsule  as  freely  as 
circumstances  will  admit.  Passing  one  hand  cautiously  into  the 
vagina,  and  forcing  the  uterus  towards  the  vulva  by  his  other  hand 
and  that  of  an  assistant,  he  now  proceeds  to  peel  back  the  capsule 
and  gradually  to  enucleate  the  mass.  Usually  the  desired  result  will 
be  accomplished,  and  an  artificial  os  thus  offered  for  escape  of  the 
tumor  from  its  capsule.  If  the  vagina  be  not  very  dilatable,  it  had 
Letter  be  prepared  for  these  manipulations  by  copious  warm  vaginal 
injections  and  gradual  distention  by  water  bags. 

If  the  second  plan^  is  decided  upon,  the  os  being  dilated  or  in- 
cised, a  long  crucial  incision  is  made  over  the  presenting  part  of 
the  tumor,  the  lips  of  the  capsule  separated  by  the  finger,  and  the 
patient  put  upon  the  steady  and  systematic  use  of  ergot,  in  the 
hope  that  the  body  of  the  tumor  may  present  through  this  species 
of  OS,  and  be  expelled  by  uterine  efforts.     A  most  interesting  case 


'  An  excellent  r^sum^  of  this  subject,  including  both  the  immediate  and  gradual 
forms  of  enucleation,  will  be  found  in  the  Med.  Times  and  Gaz.,  Aug.  1857,  by  Mr. 
J.  Hutchinson.  I  mention  this  particularly  because  some  more  recent  writers 
appear  to  regard  this  mode  of  dealing  with  fibroids  as  entirely  new. 


518 


FIBEOID    TUMORS    OF    THE    UTERUS. 


Fig.  148. 


in  whicli  this  occurred  is  recorded  by  Dr.  Grimsdale,  in  the  Liver- 
pool Med.  and  Surg.  Journal  for  January,  1857,  and  of  late  a  num- 
ber of  very  striking  cases  have  been  reported  by  Dr.  Meadows,  of 
London,  who  has  strongly  advocated  the  claims  of  this  })lan.  In 
some  cases  it  will  prove  best  to  cut  into  the  capsule,  and  thus  give 
the  tumor  an  opening  by  which  to  escape;  at  others  it  will  be  wiser 
to  detach  the  tumor  all  around  at  its  point  of  attachment  and  re- 
peat this  again  as  the  mass  descends. 

I  have  already  stated  that  when  cervical  obstruction  is  overcome 
and  the  tumor  is  liberated  from  its  retaining  capsule,  the  main 
obstacles  to  its  expulsion  are  removed.  The  process  of  enucleation 
artificially  accomplishes  what  nature  fails  to  eftect. 
Before  enucleation  by  either  method  is  resorted  to 
two  conditions  should  be  secured:  first,  full  dila^ 
tation  of  the  cervical  canal ;  second,  thorough 
information  as  to  the  attachments  of  the  tumor. 
The  methods  for  accomplishing  the  first  have  been 
mentioned.  The  second,  except  in  the  case  of 
tumors  almost  wholly  interstitial,  can  be  attained"; 
after  the  first  is  eflfected  by  use  of  the  whalebone 
rod  sliown  in  Fig.  148. 

This  being  passed  up  in  succession   along  the 
lateral,  anterior,  and  posterior  faces  of  the  tumoi 
until  it  is  obstructed  by  its  base  or  attachment,  is'^ 
measured  by  application  of  the  finger  to  its  shaft: 
at  the  OS  externum.     Thus  the  area  and  position^ 
of  the  attachment  are  fully  made  out,  and  at  the 
moment  of  operation  the  ojjerator  carries  it  as  a 
picture  in  his  mind.     Where  the  tumor  projects 
but  little  into  the  cavity  of  the  uterus,  this  means 
will   not   answer;    the   finger   must   explore    the 
attachments  of  the  almost  interstitial  growth. 
Gastrotomy. — Subperitoneal  tumors  are  much  less  amenable   to 
surgical  treatment  than  those  which  are  submucous,  but  in  com-, 
pensation  they  are  less  injurious  in  their  results.     In  some  cases,' 
however,  they  excite  so  many  evil  symptoms  as  to  call  for  removal, 
and  this  has  been  eff*ected  by  incision  through  the  abdominal  walls. 
The  operation  is  truly  a  formidable  one,  and  yet,  since  it  has  been 
repeatedly  successful  in  cases  susceptible  of  no   other   means   of 
relief,  it  is  worthy  of  consideration.     Indeed,  should  the  steudy 
decadence  of  the  patient's  strength  make  it  certain  that  a  fatal 


Elastic  whale- 
bone probe  for  as- 
certaining attach- 
ments of  intra- 
uterine growths. 


GASTROTOMY.  519 

issue  must  soon  ensue,  the  operation  in  the  case  of  a  subperitoneal 
tumor  would  become  a  matter  of  duty,  and  not  remain  one  of  choice. 

The  prospects  of  success  in  it  will  depend  very  much  upon  the 
character  of  the  attachments  of  the  tumor  to  the  uterus  and 
other  viscera  of  the  abdomen.  Unfortunately  the  extent  of  these 
cannot  be  accurately  ascertained  before  abdominal  section  and 
investigation  by  touch,  which  of  itself  involves  risk.  This  is  by 
no  means  so  considerable  as  would  at  first  be  supposed,  and  where 
doubt  exists  it  should  be  resorted  to.  Dr.  John  Clay  reports 
twenty-three  instances  in  which  it  was  adopted.  Of  these,  sixteen 
recovered,  three  died,  and  of  four  no  account  was  given  in  the 
reports. 

With  reference  to  the  propriety  of  the  operation  of  gastrotomy 
for  removal  of  uterine  fibroids  the  opinion  of  the  mass  of  the 
profession  is  at  present  adverse.  And  yet  it  is  not  more  so 
than  it  was  twenty  years  ago  with  reference  to  ovariotomy. 
It  is  highly  probable,  that,  as  experience  renders  the  operation 
safer  than  at  present,  it  will  be  resorted  to  for  the  same  reasons 
which  to-day  cause  us  to  perform  extirpation  of  ovarian  tumors, 
and  be  regarded,  as  that  operation  is,  as  a  practicable  and  expedient 
procedure.  ITot  only  is  this  opinion  sustained  by  recent  statistics, 
it  is  foreshadowed  in  the  modified  opinions  expressed  by  late  writers. 
M.  Courty,  after  stating  the  unfavorable  results  of  the  operation 
and  the  adverse  impressions  concerning  it  left  by  them,  goes  on  to 
add :  "  but  recent  operations  tend  to  modify  our  opinion  as  they 
have  done  upon  ovariotomy."^  In  saying  this  he  appears  to  have 
anticipated  what  the  future  will  bring  forth.  It  is  true  that  thus 
far  statistical  evidence  does  not  favor  it,  but  Prof.  Storer  declares, 
"that  the  mortality  of  the  earlier  uterine  extirpations  was  no 
greater  than  that  in  many  isolated  groups  of  the  other  operation." 

Pean,^  of  Paris,  reports  nine  cases  of  gastrotomy  for  fibrous  or 
fibro-cystic  tumors,  performed  by  himself,  with  the  result  of  seven 
cures  and  two  deaths.  "  Amputation  of  the  supra-vaginal  portion 
of  the  uterus,"  says  he,  "  is  not  an  operation  of  much  graver  cha- 
racter than  extirpation  of  ovarian  cysts  complicated  by  adhesions." 
.  .  .  .  "  Ablation  of  the  uterus,"  he  continues,  "  is  a  perfectly 
justifiable  operation,  which  the  surgeon  is  as  much  warranted  in 
undertaking  under  certain  circumstances  as  ovariotomy."  P^an 
gives  the  results  of  forty-four  cases,  by  different  operators,  of  par- 
tial or  complete  ablation  of  the  uterus  by  gastrotomy.     Out  of 

'  Op.  cit..  p.  977. 

'  Hysterotoniie,  by  J.  Pean  aud  L.  Urdy.     Paris,  1873. 


520 


FIBROID    TUMORS    OF    THE    UTERUS. 


this  number  fourteen  recovered  and  thirty  died,  an  equivalent  of 
recoveries  of  31.82  in  100. 

It  is  certainly  not  venturing  too  much  to  say  that  if  the  fibroid 
be  pedunculated  and  unattached,  its  removal  is  not  much  more 
dangerous  than  the  ordinary  operation  of  ovariotomy  ;  that  if  it  be 
completely  amalgamated  with  the  uterus,  or  so  bound  to  neigh- 
boring parts  that  removal  proves  very  difficult,  the  operation  may 
be  abandoned,  the  patient  having,  without  great  risk,  availed  her- 
self of  the  only  chance  of  cure ;  and  that  even  if  the  removal  of 
the  tumor  involve  that  of  the  uterus  and  ovaries,  we  may  still 
indulge  in  a  hope  of  saving  our  patient,  as  the  following  table, 
arranged  by  Prof.  II.  R.  Storer,*  will  prove : 

Operations. 


Clay,        . 
Heath,     . 
Barnham, 
Kimball, 
Parkman, 
Peaslee, 
Koeberle, 
Baker  Brown, 
Wells,      . 
Sands, 

Buckingham, 
Storer,     . 


Deaths. 
2 
1 
1 
2 
1 
1 
0 
1 
1 
1 
1 
0 


24  18 

Recoveries  1  in  4,  or  25  per  cent. 

The  statistics  here  displayed,  although  showing,  as  they  do,  a 
large  mortality,  would,  I  fear,  lead  one  to  take  a  more  favorable 
view  of  the  results  of  this  operation  than  enlarging  experience 
will  warrant.  Since  their  publication  the  uterus  has  been  re- 
moved in  this  country  with  the  following  results  :^ 

Storer,"  of  Boston,   . 
Cutter,"  of  Newark, 
Wood,^  of  Cincinnati, 
Hackenberg-.''  of  Hudson, 
Atlee,"  Philadelphia, 
Weber,''  Cleveland, 
Gaillard  Thomas,'    .         . 

12  11 


■itions. 

Deaths. 

4 

4 

2 

2 

1 

1 

2 

1 

1 

'  "  On  Removal  of  the  Womb  and  both  Ovaries." 
2  I  leave  this  statement  as  it  was  made  in  1872. 

"  Personal  communication.  *  N.  Y.  Med.  Record,  Jan    18.  1868. 

'  Uterus  and  both  ovaries  removed  with   fibrous  tumor  weighing  fifty  pounds, 
May  19,  1874. 


GASTROTOMY.  521 

1^0  operator  sliould  undertake  gastrotomy  for  a  uterine  fibroid 
without  being  prepared,  if  necessary,  to  remove  the  uterus  with  the 
tumor,  for  the  connection  is  often  so  intimate  that  a  determination 
of  the  attachments  of  the  tumor  is  out  of  the  power  of  the  most 
skilful  diagnostician.  Indeed,  even  after  removal  of  the  mass  from 
the  body,  its  relations  to  the  uterus  are  often  discovered  only 
after  patient  and  intelligent  search.  Dr.  Farre  tells  of  a  specimen 
preserved  in  one  of  the  London  museums  as  a  solid  ovarian  tumor 
which,  upon  careful  examination,  he  proved  to  be  uterine  by 
tracing  the  Fallopian  tubes  into  it.  It  was  also  in  this  way  that 
the  nature  of  one  of  the  tumors  removed  by  Dr.  Storer  was  identi- 
fied ;  Prof.  Ellis,  after  very  minute  examination,  distinctly  discover- 
ing the  entrance  of  the  tubes  into  the  cavity  of  the  body,  and 
thus  settling  the  matter. 

The  operation  is  performed  in  exactly  the  same  manner  as 
ovariotomy,  with  this  exception — the  pedicle  of  the  tumor  is  the 
uterine  neck  or  upper  portion  of  the  vagina.  This  part  being 
punctured,  a  double  ligature  is  passed,  and  the  two  portions  tied. 
The  accidents  which  have  generally  produced  a  fatal  termination 
in  cases  of  gastrotomy  are  as  follows : 

1st.  Primary  or  secondary  shock  or  collapse; 
2d.  Hemorrhage ; 
3d.  Peritonitis ; 
4th.  Septicaemia. 

As  Prof.  Storer  points  out,  we  are  now  possessed  of  means  for 
limiting  the  first ;  the  improved  methods  of  hemostasis  at  our 
command  diminish  the  danger  of  the  second  ;  and  the  knowledge 
of  the  fact  that  keeping  the  peritoneum  free  of  blood  and  other 
fluids  l)y  drainage  markedly  diminishes  the  probability  of  the  oc- 
currence of  the  third  and  fourth,  will  in  future  aid  in  avoiding  them. 

I  have  endeavored  to  lay  the  facts  connected  with  gastrotomy 
for  uterine  neoplasms  before  the  reader  in  their  true  light,  care- 
fully avoiding  any  partial  or  prejudiced  representation  concerning 
them.  What  position  the  future  wnll  assign  to  the  operation  no 
one  can  at  present  declare,  but  of  this  we  may  even  now  be  sure, 
that  they  are  culpably  barring  the  way  to  advancement  who  refuse 
to  attempt  the  only  plan  by  which  life  may,  at  times,  be  saved, 
and  screen  themselves  from  blame  in  so  doing  by  casting  censure 
and  reproach  upon  those  who  endeavor  to  afford  the  patient  every 
chance  for  life. 

I  have,  in  cases  of  uterine  fibroids,  resorted  to  every  one  of  the 


[)22 


FIBROID    TUMORS    OF    THE    UTERUS. 


Fisr.  140. 


methods  here  described,  and  recommend  none  of  them  upon  theo- 
retical grounds  alone.  Each  case  will  require  its  own  carefully 
selected  remedy  ;  and  success  will  be  greatly  influenced  by  wisdom 
in  the  choice.  Let  me  endeavor  to  lay  before  the  reader  certain 
rules,  which  may  guide  him  in  his  determination. 

1st.  In  the  case  of  a  tumor  which  projects  into  the  uterine  cavity, 
ofi:ering  a  resting  place  for  the  chain  of  an  ^craseur  or  the  wire  of 
the  galvano-cautery,  these  should  be  employed  in  its  removal. 
Should  their  application  not  be  practicable,  or  should  the  attach- 
ment of  the  growth  be  small,  and  be  attainable  by  scissors,  they 
should  be  employed. 

2d.  When  the  tumor  is  of  such  a  character  that  although  bulging 
into  the  uterine  cavity  it  cannot  be  excised,  nor  grasped  by  a  me- 
tallic loop,  avulsion  should  be  resorted  to. 

3d.  If  the  tumor  be  to  a  certain  extent  interstitial,  or  be  attached 

by  a  very  extensive  base,  as  in  Fig. 
149,  enucleation  ofters  itself  as  a 
most  valuable  resource. 

4th.  When  the  tumor  is  sub- 
serous, and  it  is  apparent  that  its 
continuance  will  destroy  the  life 
of  the  patient,  gastrotomy  is  the 
last  resort. 

5th.  To  recapitulate,  no  absolute 
rule  can  be  given  as  to  choice  of 
procedure  in  cases  of  this  affection. 
In  a  general  way,  it  may  be  said, 
if  excision,  ecrasement,  or  galvano- 
cautery  can  be  accomplished  with- 
out great  amount  of  manipulation 
within  the  uterine  cavity^  they  should 
be  preferred.  If  the  tumor  project 
decidedly  into  the  uterine  cavity, 
and  its  base  be  found  not  to  be 
very  large,  avulsion  should  be  resorted  to.  Should  its  base  be  large, 
or  the  growth  be  in  great  degree  interstitial,  enucleation  offers  the 
best  chance  of  success.  If  immediate  enucleation  be  practicable,  it 
should  be  preferred.  If  it  require  too  violent  and  prolonged  efforts, 
gradual  enucleation  should  be  selected. 

Success  in  these  operations  does  not  depend  upon  skill  in  the 
removal  of  the  growth,  nearly  so  much  as  it  does  upon  the  opera- 
tor having  previously  obtained  full  dilatation  of  the  cervical  canal. 
Gastrotomy  should  be  performed  only  when  life  is  in  jeopardy. 


Submucous  fibroid. 


FIBRO-CYSTIG    TUMORS    OF    THE    UTERUS.  523 


CHAPTER  XXXII. 

CYSTO-FIBROMATA,  OR   FIBRO-CYSTIC   TUMORS  OF  THE  UTERUS. 

Definition^  Synonyms^  and  Frequency. — The  form  of  compound 
ateriiie  tumor  which  we  are  now  considering  lias  been  described  by 
different  authors  under  the  names  of  cysto-fibroma,  cysto-sarcoma, 
cystoid,  and  fibro-cystic  tumor. 

Our  knowledge  of  these  tumors  is  but  recently  acquired,  and  is 
even  now  exceedingly  elementary.  In  two  of  its  most  important 
aspects,  diagnosis  and  differentiation  from  other  forms  of  abdomi- 
nal tumor,  we  have  been  very  deficient,  and  from  this  have  resulted 
frequent  and  serious  errors.  Considerable  attention  is,  however, 
being  now  directed  to  the  subject,  and  already  we  are  possessed  of 
means  which  were  wanting  only  a  few  years  ago  for  arriving  at 
correct  and  certain  conclusions  concerning  them. 

Cysts  may  develop  in  connection  with  the  uterus  in  two  entirely 
difierent  ways;  first,  a  cyst  may  grow  and  become  very  large,  being 
enveloped  by  a  layer  of  uterine  tissue;  second,  solid  tumors  of  the 
uterus,  whether  benign  or  malignant,  may  undergo  cystic  degene- 
ration, that  is  to  say,  within  the  structure  of  a  solid  tumor  cysts 
may  develop,  which,  distending  the  spaces  in  which  they  first  form, 
gradually  increase  in  size,  and  it  may  be  in  number,  until  what  was 
formerly  a  solid  growth  becomes  in  certain  parts  filled  with  fiuid. 
Thus  we  may  have  cysto-sarcoma,  cysto-fibroma,  cysto-chondroma, 
or  cysto-carcinoma. 

It  must  not  be  supposed  that  this  variety  of  tumor  compares  in 
frequency  with  the  simple  fibroid,  or  that  cystic  degeneration  often 
aftects  that.  It  is  not  a  matter  of  very  common  occurrence,  but  it 
is  certainly  sufficiently  common  to  demand  especial  consideration 
•at  the  hands  of  the  gynecologist.  As  has  been  the  case  too  with 
many  other  affections,  as  soon  as  special  attention  has  been  directed 
to  it,  it  has  been  found  to  be  much  more  frequent  in  occurrence 
than  was  previously  supposed.  Up  to  the  year  1869,  Koebcrle'  tells 
us  that  only  fourteen  cases  had  been  recorded,  of  which  two  were 

'  Gazette  Hebdoni.,  No.  16,  1869. 


524  FIBKO-CYSTIC    TUMORS    OF    THE    UTERUS. 

discovered  post-mortem.  Dr.  C.  C.  Lee,^  however,  in  that  year, 
collected  the  reports  of  nineteen  cases,  nine  in  this  country,  eight 
in  England,  and  two  in  France.  Dr.  E.  R.  Peaslee,^  writing  in  1872, 
says,  "I  have  myself  met  with  ten  cases  in  the  last  two  years,  and 
have  seen  not  less  than  fifty  since  my  first  operation  of  ovariotomy 
in  1850. 

Patliology. — Pathologists  descrihe  a  variety  of  methods  hy  which 
spaces  may  he  created  within  fihroid  tumors,  which,  suhsequently 
becoming  lined  by  a  fluid-secreting  membrane,  are  filled  with 
serous,  sero-sanguinolent,  or  colloid  material.  "Within  some 
fibroid  tumors,"  says  Klob,^  "cavities  may  be  found,  which  may 
have  occurred  in  several  ways.  They  either  result  from  a  dropsical 
condition,  or  the  connective  tissue  of  the  tumor  undergoes  colloid 
metamori)hosis  (mucous  degeneration),  commencing  at  the  centre 
of  the  tumor,  and  in  consequence  of  which  its  substance  liquefies 
into  an  albumino-serous  fluid.  Finally,  hemorrhages  into  the  sub- 
stance of  a  tumor  may  lead  to  the  formation  of  cavities  similar  to 
the  so-called  '  apoplectic  cysts.'  "  In  speaking  of  neoplastic  cysts, 
Billroth^  says,  "These  result  mostly  from  softening  of  tissue  previ- 
ously diseased  by  cell-infiltration,  or  a  firm  tumor  substance.  As 
soon  as  the  new  formation  has  separated  into  sac  and  fluid  contents, 
in  some  cases  a  secretion  from  the  inner  wall  of  the  sac  begins,  so 
that  the  softening  cyst  becomes  a  secretion  or  exudation-cyst,  and 
thus  grows.  Any  tissue  rich  in  cells  may  be  transformed  into  a 
cyst  by  mucous  metamorphosis  of  the  protoplasm,  or,  as  others 
express  it,  by  separation  of  the  mucous  substance  through  cells 
without  any  connection  with  development  of  mucous  glands."  He 
then  goes  on  to  liken  the  process  by  which  fluid  spaces  are  created 
in  chondromata  and  fibromata  to  the  formation  of  the  joints  in  the 
limbs  of  the  foetus  by  mucous  softening  of  the  cartilage  tissue,  of 
which  the  bones  of  the  limbs  are  formed.  Furthermore  he  declares, 
that  "the  often  slit-shaped,  smooth-walled  cysts  with  serous,  or 
sero-mucous  contents  which  occur  in  uterine  myomata,  are  possibly 
enormously  dilated  lymph  spaces,"  a  view  which  was  first  advanced 
by  Cruveilhier. 

It  will  be  seen  that  the  term  cystic  degeneration  is  rather  loosely 
applied  to  this  affection,  for  the  fluid  collections  taking  place  are 
rather  results  of  liquefaction  than  of  true  cyst  development.  Never- 
theless I  shall  adhere  to  its  use. 

'  Remarks  upon  Diagnosis  of  Ovarian  from  Fibro-Cystic  Tumors. 
2  Ovarian  Tumors,  p.  107,  3  Op.  cit. 

*  Op.  cit.,  p.  621. 


PATHOLOGY.  525 

Cystic  degeneration  affects  submucous  or  interstitial  fibroids 
much  less  frequently  than  those  which  are  subserous.  The  following 
case  re})orted  by  Dr.  Sims,  which  he  considers  one  of  this  degene- 
ration in  a  submucous  fibroid,  is  worthy  of  citation.  It  is  described 
by  him  in  these  words:  "I  passed  a  trocar  into  it  at  its  lowest 
point,  and  in  the  direction  of  its  long  axis,  and  there  were  dis- 
charged more  than  twenty  ounces  of  a  colored  serum.  The  puncture 
was  enlarged  for  two  inches  to  prevent  its  closing.  There  Avas  at 
once  a  sensible  diminution  in  the  size  and  tension  of  the  abdomen. 
The  discharge  kept  up  for  some  time ;  ^nd  this,  together  with 
occasional  injections  into  the  very  fundus  of  the  uterus,  with  the 
liquor  ferri  persulphatis,  diluted  with  three  or  four  parts  of  water, 
arrested  very  promptly  the  hemorrhages,  and  the  patient  was 
dismissed  in  two  months  in  a  very  comfortable  condition,  and  with 
strength  enough  to  walk  six  or  eight  miles." 

As  the  records  of  cases  of  fibro-cystic  tumors  are  not  very 
commonly  met  with  in  the  literature  of  this  subject,  I  shall  make 
reference  to  a  few  of  them.  Kiwisch'  described  one  M'hicli  filled 
the  Avhole  pelvic  cavity,  and  extended  as  high  as  the  ensiform 
cartilage.  It  took  its  rise  from  the  posterior  uterine  wall ;  had  as 
its  base  a  fibroid  tumor  the  size  of  the  head,  which  was  enveloped 
in  uterine  substance;  and  weighed  forty-six  pounds.  Cruveilhier^ 
mentions  a  similar  one.  Spencer  AV^ells^  speaks  of  two  cases.  In 
one  the  tumor  was  connected  with  the  right  side  of  the  fundus  by 
abroad  band;  its  solid  portion  weighed  sixteen  pounds ;  its  fluid 
portion  twenty-six ;  and  a  semifluid  material  four  pounds.  The 
uterus  was  twice  its  natural  size.  In  the  other  there  were  two 
tumors,  both  of  which  had  a  uterine  attachment,  and  consisted  of 
solid  and  fluid  elements.  A  very  striking  instance  of  this  affection 
I  saw  submitted  to  operation  by  Dr.  James  L.  Little  of  this  city. 
The  tumor,  which  yielded  very  obscure  fluctuation,  filled  the  entire 
abdominal  cavity,  and  was  composed  of  a  network  of  fibrous  tissue, 
constituting  spaces  varying  in  size  from  that  of  an  apple  to  that  of 
a  cocoanut,  which  were  filled  with  colloid  material.  This  growth 
sprung  from  the  neck  of  the  uterus.  It  took  its  origin  from  the 
l)Ost-cervical  wall,  and  the  tumor  growing  from  this  pedicle  filled 
the  whole  abdominal  cavity,  and  was  before  operation  regarded  as 
ovarian. 


'  Quoted  by  Klob,  op.  cit.,  p.  182.  «  Klob,  op.  cit.,  p.  182. 

*  Diseases  of  Ovaries,  p.  354. 


526  FIBRO-CYSTIC    TUMORS    OF    THE    UTERUS, 

Symptoms. — Fihro-cystic  tumors  do  not  vary  in  symptoms  from 
subperitoneal  fibroid  growths  of  equal  size.  Like  them  they  pro- 
duce— 

Displacements  of  the  uterus; 

Pressure  on  rectum  and  bladder; 

Menorrhagia  in  some  cases. 

Physical  Signs. — The  uterus  is  usually  found  to  be  enlarged  from 
excess  of  nutrition  resulting  from  the  formative  irritation  due  to 
the  propinquity  and  connections  of  the  tumor,  and  to  be  elevated 
and  lie  in  front  of  it.  The  sensation  yielded  by  bimanual  manipu- 
lation and  by  palpation  is  not  that  of  a  hard,  solid,  and  resisting 
mass,  but  an  obscurely  fluctuating  sensation  is  discovered.  It  is 
common  in  such  cases  to  find  a  certain  number  of  examiners  in- 
clining to  the  theory  of  fluidity,  and  others  to  that  of  solidity  in 
the  growth.  If  an  explbrative  tapping  be  practised  by  the  hypo- 
dermic syringe,  a  very  small  amount  of  fluid,  which  is  usually 
viscid  or  turbid,  will  be  withdrawn  from  some  places,  while  no 
fluid  Avhatever  will  appear  from  others,  and  if  a  trocar  or  a  large 
needle  of  the  aspirator  be  em})loyed  a  quart  or  two  of  thick  straw- 
colored  fluid  may  be  drawn  off,  leaving,  usually,  solid  elements  re- 
maining. In  rare  cases  of  large  uterine  cysts  the  sac  would  be 
entirely  emptied,  and  even  these  signs  would  be  wanting. 

Differentiation. — Many  competent  authorities  have  declared  that 
the  diagnosis  of  this  form  of  tumor  and  its  differentiation  from 
ovarian  cyst  is  impossible.  Kocberl^  says,  "  the  diagnosis  of  fibro- 
cystic tumors  has,  up  to  the  present  time,  been  declared  impossible 
by  almost  every  author,"  and  Baker  Brown  acknowledges  that  he 
knows  of  "  no  distinguishing  marks  between  the  two."  Even  after 
incision  Spencer  Wells  declares  that  he  knows  of  nothing  l)ut  a 
darker  hue  of  the  sac-wall  to  put  the  operator  on  his  guard.  The 
result  of  this  difiiculty  is  illustrated  by  the  fact  that  out  of  Lee's 
nineteen  cases  eighteen  were  operated  on  under  a  mistaken  diag- 
nosis of  ovarian  cyst. 

The  conditions  with  which  this  form  of  tumor  will  most  likely 
be  confounded  are — 

Pregnancy ; 

Fibroid  tumor  of  the  uterus; 

Ovarian  cyst. 

From  the  first  it  may  be  known  by  absence  of  the  gastric  and 
mammary  symptoms  of  that  condition,  by  menstruation  not  only 
continuing  but  perhaps  showing  a  tendency  to  increase  in  amount 


DIFFERENTIATION.  527 

and  frequency,  by  absence  of  foetal  movements  and  heart  sounds, 
and  by  the  duration  of  the  tumor  beyond  nine  months. 

From  fibroid  tumor  it  may  be  known  by  its  yielding  obscure 
fluctuation,  its  assuming  usually  larger  proportions,  its  more  rapid 
growth,  and,  beyond  everything  else,  by  its  yielding  fluid  to  the 
exploring  trocar. 

From  ovarian  cyst  diagnosis  is  usually  difficult  and  often  impos- 
sible: the  chief  grounds  upon  Avhich  it  will  always  depend,  and 
upon  which  it  may  sometimes  be  made,  are  the  following : 

Shape  and  density  of  the  tumor; 

Its  connection  with  the  uterus ; 

The  depth  of  the  uterus; 

The  rapidity  of  growth  and  effect  on  health ; 

The  effects  of  tapping ; 

The  characters  of  the  fluid  wididrawn.  < 

There  are  many  other  differential  signs,  but  these  are  the  really 
reliable  ones.  A  great  array  of  symptoms  often  confuses  rathei 
than  helps  the  inexperienced  diagnostician,  and  I  wish  to  analyze 
the  subject  here  as  it  should  be  analyzed  at  the  bedside. 

When  a  diagnosis  is  arrived  at  it  is  ordinarily  done  in  the  fol 
lowing  way : 

1st.  The  examiner  in  palpating  has  been  struck  by  the  fact  that 
the  surf\\ce  of  the  tumor  which  he  supposes  to  be  ovarian  is  pecu- 
liarly irre2:ular  and  resisting  to  the  touch,  and  that  fluctuation  is 
obscurely  yielded  in  certain  places  only.  This  renders  him  sus- 
picious, and  he  determines  to  investigate  fully  before  committing 
himself  to  the  diagnosis  which  at  first  suggested  itself. 

2d.  He  now  examines  the  uterus  and  finds  that  the  sound  proves 
it  to  be  three  and  a  half  or  four  inches  deep ;  that  as  he  rotates 
this  organ  upon  the  sound  it  appears  united  to  the  tumor ;  that 
posteriorly  to  the  uterus  the  tumor  seems  to  join  it  and  grow  from 
it ;  and  that  as  an  assistant  lifts,  depresses,  and  rolls  the  tumor  the 
uterus  moves  distinctly.     His  suspicions  are  strengthened. 

3d.  He  now  questions  the  patient  more  closely,  finds  that  she  is 
over  thirty,  (fibro-cystic  tumors  rarely  appear  befoi'e  thirty,)  and 
that  this  tumor  has  been  slowly  but  steadily  growing  for  four  or 
five  years  without  materially  impairing  her  health.  He  feels  the 
necessity  for  further  information,  and  resorts  to  removal  of  the 
fluid  by  the  aspirator  or  trocar. 

4th.  The  fluid  which  pours  away  is  trans[>arent  and  straw-colored, 
and  as  it  ceases  to  flow  he  discovers  that  the  sac  only  in  part  col- 


528 


FIBRO-CYSTIC    TUMORS    OF    THE    UTERUS. 


lapses.  Testing  the  matter,  lie  finds  that  this  is  not  due  to  the 
existence  of  other  cysts,  but  that  solid  elements  prevent  collapse. 

5th,  He  now  examines  the  fluid  withdrawn,  and  finds  that  it 
coagulates  spontaneously  as  well  as  under  heat.  The  whole  con- 
tents of  the  tube  give  a  large  coagulum  like  that  of  the  blood  clot 
in  consistence  though  not  in  color.  Placed  under  the  microscope, 
a  peculiar  fibre  cell  is  discovered,  which  is  characteristic,  according 
to  Dr.  Atlee,  of  the  fluid  of  fibro-cystic  and  not  of  ovarian  tumors. 
It  is  a  product  derived  from  the  tissue  in  which  the  cyst  forms 
itself,  tlie  muscular  tissue  of  the  uterus. 

From  all  but  the  last  of  these  means  only  a  doubtful  conclusion 
could  be  drawn,  for  every  one  of  them  is  often  fallacious  in  typical 
cases,  and  always  so  in  large  cysts  unaccompanied  by  any  fibrous 
structure  except  that  constituting  their  walls.  The  tumor  may  not 
be  irregular  nor  hard ;  it  may  develop  with  great  rapidity ;  the 
uterus  may  not  increase  in  depth,  may  move  independently  of 
the  tumor;  and  tapping  may  empty  it.  On  the  other  hand,  cases 
of  true  ovarian  tumor  are  not  rarely  met  with  in  which  the  uterus 
is  increased  in  deptli,  tlie  tumor  and  uterus  move  synchronously 
under  slight  impulse,  tapping  onl}'  partially  empties  the  sac,  leaving 
solid  masses  remainino-,  and  the  growth  of  the  tumor  is  slow  and 
has  little  influence  upon  the  general  health.  Dr.  W.  L.  Atlee'  most 
truly  remarks,  that  "  no  amount  of  experience  will  avail  the  sur- 

Fijr.  150. 


The  fibre  cell  (a)  characteristic  of  fihro-cystic  tumors. 

geon  in  making  a  diflferential  diagnosis  by  the  ordinary  methods 
of  examination."  "  But,"  saj^s  that  eminent  ovariotomist  in  allud- 
ing to  his  past  errors  of  diagnosis,  "  such  errors  need  not  be  re- 

'  Ovarian  Tumora,  p.  263. 


TREATMENT.  529 

peated."  lie  believes  that  we  have  now  arrived  at  a  period  when 
diagnosis  becomes  at  once  simple  and  positive.  Should  the  diag- 
nostic method  which  he  has  furnished  us  bear  the  test  of  experi- 
ence, a  most  important  result  will  indeed  have  been  attained.  Dr. 
Atlee  relies  upon  the  physical  properties  of  the  fluid  withdrawn 
from  these  sacs  for  diagnosis  of  their  origin,  whether  uterine,  ova- 
rian,  or  of  the  broad  ligaments.  The  characters  of  fibro-cj'stic  fluid 
are  these.  It  is  transparent,  of  a  deep  amber  color,  and  very  thin 
when  first  drawn,  but  forms  a  hard  and  firm  coagulum  in  a  little 
while,  which  in  a  few  hours  shrinks  and  separates  into  a  clot  and  a 
thin  watery  serum.  It  coagulates  by  heat,  and  resembles  in  every 
respect  the  liquor  sanguinis.  Under  the  microscope  few  cells  appear 
in  it.  There  are  epithelium,  oil  globules,  and  a  fibre  cell,  repre- 
sented at  A  in  Fiff.  150.  This  is  characteristic  of  the  structure  in 
which  the  cyst  originated. 

Course^  Duration,  and  Termination. — This  form  of  tumor  runs  a 
very  slow  course.  Much  graver  and  more  rapid  in  development 
than  the  jjure  fibroid,  it  develops  more  slowly  than  ovarian  cyst. 
I  have  recently  had  under  observation  two  very  large  tumors  sup- 
posed to  be  of  this  kind.  One  of  them  had  existed  for  eleven  years, 
and  yet  the  patient  still  performed  the  functions  of  nurse  in  a 
hospital.  It  is  true  that  her  abdomen  was  immensely  distended, 
and  that  she  moved  about  with  ditficulty,  but  thus  far  she  had  not 
been  completely  incapacitated.  In  the  second  case  the  tumor  had 
existed  for  about  five  years.  It  was  quite  large,  when  the  patient, 
after  an  attack  of  illness  which  was  supposed  by  her  physician  to 
be  peritonitis,  began  to  improve,  and  is  now  reported  to  me  as 
being  better  than  she  was  before. 

Although  this  is  the  slow  course  of  the  affection  in  some  cases, 
in  others  it  exhausts  the  patient  by  constitutional  irritation,  the 
result  of  mechanical  interference  with  other  organs,  menorrhagia, 
and  deprivation  of  exercise  and  fresh  air. 

Prognosis. — The  prognosis  is  unfavorable.  Relief  by  medication 
is  in  the  present  state  of  therapeutics  unattainable,  and  the  opera- 
tion of  gastrotomy  is  much  less  promising  when  performed  for 
uterine  than  for  ovarian  tumors. 

Treatment. — ITothing  more  need  be  stated  in  reference  to  this 
subject  than  has  been  already  said   in  connection  with  uterine 
fibroids,  and  will  be  said  in  speaking  of  ovariotomy. 
34 


530  UTEEINE    POLYPI. 


CHAPTER    XXXIII. 

UTERINE  POLYPI. 

Definition. — A  uterine  polypus  is  a  tumor  covered  by  the  mucous 
membrane  of  the  uterus,  attached  to  tliat  organ  by  a  pedicle  or 
stem,  and  originating  in  a  hypertrophy  or  hyperplasia  of  some  of 
its  proper  tissues.  Portions  of  placenta,  the  fibrinous  remains  of 
blood  clots,  and  parts  of  the  foetal  envelopes,  sometimes  remain  in 
utero,  and  take  upon  themselves  the  shape  and  develop  the  symp- 
toms of  true  polypi.  They  might,  with  justice,  be  described  as 
pseudo  polypi,  but  the  true  polyjius  originates  in  morbid  growth 
of  the  tissues  of  the  organ  from  which  it  8j)ring8. 

History. — While  so  many  uterine  disorders  of  great  obscurity 
are  described  by  the  earliest  medical  writers,  this,  the  diagnosis  of 
which  is  often  so  self-evident  and  positive,  attracted  little  attention. 
Hippocrates,  Celsus,  Galon,  and  even  Aetius  make  no  mention  of  it. 
By  Moschion  it  was  described  in  the  third  century,  and  called 
pulps  or  polypus,  but  it  was  certainly  neither  well  understood  nor 
treated  in  his  time,  and  we  get  no  clear  accounts  of  it  until  the 
revival  of  this  branch  of  learning  by  the  French  School  in  the 
seventeenth  century.  Then  Guillemeau,  and  subsequently  Lcvret, 
threw  much  light  upon  it,  and  in  the  latter  part  of  the  eighteenth 
and  beginning  of  the  nineteenth  centuries  many  others  contributed 
to  place  our  knowledge  upon  its  present  basis. 

Varieties. — The  student  will  meet  with  much  difficulty  in  arriv- 
ing at  definite  ideas  concerning  the  varieties  of  uterine  polypi. 
Almost  all  authors  differ  in  their  classification,  and  the  number 
of  names  which  have  at  various  times  been  ajtplied  to  them  is  too 
large  even  for  repetition.  Lot  it  be  borne  in  mind  that  since  these 
tumors  are  formed  by  excessive  development  of  one  of  the  tissues 
existing  in  the  uterus,  there  are  but  three  elements  which  can  give 
rise  to  them :  the  muscular  tissue ;  the  connective  tissue ;  or  the 
glands  of  the  organ.  It  is  true  that  by  some  a  species  of  vascular  i 
polypus  formed  from  development  of  the  bloodvessels,  a  species  of 
telangiectasis,  has  been  described,  but  it  is  probable  that  this  is 
only  a  form  of  the  cellular  or  mucous  variety.     All  classifications 


PATHOLOGICAL    ANATOMY. 


531 


of  these  growths  are  to  a  great  extent  arbitrary,  and  hence  in  the 
present  state  of  pathology  none  can  become  universal.  That  which 
I  shall  adopt  is  this: 

1st.  Cellular      polypi; 

2d.    Glandular 

3d.    Fibrous  " 

These  varieties  are  subject  to  morbid  changes  which  create  other 
forms ;  as,  for  example,  fatty,  calcareous,  and  malignant  polypi. 
Colombat  refers  to  a  large,  hollow  polypus  which,  when  removed. 
leads  the  operator  at  first  to  fear  that  he  has  mistaken  an  inverted 
uterus  for  a  polypus.  He  states  that  Richerand  and  Jules  Cloquet 
were  once  thus  deceived,  until  the  subsequent  death  of  the  patient 
enabled  them  to  correct  their  error  by  post-mortem  inspection. 
Alme.  Boivin  represents  one  of  this  cliaracter,  in  Plate  19  of  her 
work.  She  calls  it  a  hollow  polypus;  declares  that  before  its  remo- 
val by  M.  Dubois,  it  was  regarded  as  inversion  by  several  phy- 
sicians, and  accounts  for  it  by  supposing  that  some  plastic  ele- 
ment had  coated  the  uterus  and  been  ripped  off,  except  at  its  cer- 
vical attachment,  and  had  become  inverted  by  menstrual  fluid 
collected  above.  Some  years  ago  Dr.  Henschel  presented  to  the 
Xew  York  Obstetrical  Society  a  hollow  polypus  which  was  attached 
to  the  cervix  by  three  points.  It  was  referred 
to  Dr.  Noeggerath  for  examination  and  report, 
and  his  method  of  accounting  for  it  was  similar 
to  that  of  Mme.  Boivin  in  the  case  just  men- 
tioned. 

Pathological  Anatomy. — The  cellular  poly})US 
is  a  tumor,  generally  of  pear  shape,  varying  in 
size  from  a  marble  to  a  hen's  e^g.  It  is  covered 
over  by  mucous  membrane,  and  consists  within 
of  connective  tissue  in  a  state  of  hypertrophy 
or  hypergenesis.  Its  attachment  is  generally, 
though  not  always,  to  one  wall  of  the  cervix, 
and  in  its  structure  there  appears  a  certain 
amount  of  cervical  fibrous  tissue.  Sometimes 
the  pedicle  of  this  variety  is  very  long  and  slen- 
der, so  that  it  hangs  outside  of  the  vulva. 

The  glandular  polypus  consists  in  hypertrophy 
of  the  Nabothian  glands,  or,  according  to  Dr. 
Farre,  of  the  utricular  follicles.     Several  follicles  are  enlarged,  and, 
being  bound  together  by  connective  tissue,  make  up  a  tumor  of 


Fig.  151. 


A  cellular  polypus 
attached  within  the 
cervix  uteri. 


532 


UTERINE    POLYPI. 


pecliculatecl  form.     It  may  arise  either  from  the  cervix  or  body, 
but  very  generally  grows  from  the  former,  and  is  commonly  gre- 
garious, a  large  number  of  very 


Fig.  152. 


Glandular  polypns. 


Fiji-.  153. 


A  snbmncons  fihroid  being  gradually 


small  ones  often  studding  the  walls 
of  the  cervical  canal.  The  most 
remarkable  instance  of  this  variety 
with  which  I  have  ever  met  is  that 
represented  in  Fig.  152.  The 
whole  growth  measured  in  length 
4 J  inches,  and  in  longest  diameter 
2|  inches.  It  filled  the  vagina 
comiilctely,  grew  from  inner  wall 
and  lip  of  the  cervix,  caused  no 
symptom  except  Icucorrhoea  and 
pelvic  neuralgia,  and  was  not  sus- 
pected until  difficulty  in  sexual  in- 
tercourse caused  tlie  patient  to  ap- 
ply for  examination.  The  mass 
was  examined  after  removal  by  Dr. 
F.  Dclafield,  and  found  to  consist 
of  enlarged  cervical  follicles,  (the 
grai)e-like  masses  shown  in  the 
diagram,  which  was  copied  from 
nature  by  Dr.  J.  B.  Hunter,)  bound 
together  by  connective  tissue.  I 
removed  it  with  great  ease  by  the 
^craseur. 

The  fibrous  polj-pus  is  a  sub- 
mucous fibroid,  resembling  closely 
those  which  are  subserous  and  in- 
terstitial. Slowly  extruded  from 
the  uterine  parenchyma  by  its 
contraction,  the  tumor  gradually 
acquires  a  pedicle  and  becomes  the 
form  of  polypus  under  considera- 
tion. Fibrous  polypi  usually  arise 
from  the  body  of  the  uterus,  though 
they  are  sometimes  attached  to 
the  rim  of  the  os. 

Causes. —  Any    chronic    inflara- 


transformed  into  a  fii)rous  polypus.         matory  action,  any  obstruction  to 


PHYSICAL    SIGNS.  533 

escape  of  menstrual  blood  which  causes  uterine  tenesmus,  or  any 
influence  tending  to  keep  up  uterine  congestion,  will  predispose  to 
hjpergenesis  of  the  elements  of  the  mucous  membrane.  But  as  for 
fibroids,  so  for  fibrous  polypi,  no  positive  cause  is  known. 

Symptoms. — Polypi  occasion  two  classes  of  symptoms ;  one  de- 
pendent upon  the  congestion  which  their  presence  excites,  the  other 
upon  the  mechanical  obstruction  which  they  offer  to  the  escape  of 
\nenstrual  blood.    These  two  infl  uences  result  in  the  following  signs : 

Leucorrhoea ; 

Pain  in  back  and  loins  ; 

Menorrhagia ; 

Metrorrhagia ; 

Iljdrorrhoea ; 

Dysmenorrhoea. 

The  last  of  these  is  not  a  frequent  sign,  but  sometimes  presents 
itself  prominently,  as  it  did  in  the  following  case,  which  occurred 
l)efore  we  understood  the  use  of  tents  as  we  do  at  present.  A 
lady  came  from  a  distance  to  put  herself  under  Dr.  Metcalfe's  care 
for  dysmenorrhoea,  characterized  by  severe  tenesmus  and  expulsion 
of  clots.  These  symptoms  had  lasted  for  years,  and  had  resulted 
in  emaciation,  and  great  nervousness  and  irritability.  In  time  slic 
came  under  my  care ;  was  treated  by  me  for  nearlj'"  a  year,  and 
went  home  unrelieved.  At  her  next  menstrual  period  she  sent  for 
tlie  physician  of  the  neighborhood,  who  examined  l^y  touch,  detected 
in  the  vagina  a  small  polypus  which  hung  by  a  stem  from  the 
uterus,  and  twisted  it  ofl:',  to  her  complete  and  permanent  relief. 
This  had  been  at  last  expelled  after  having  rested  upon  the  os 
internum,  and  acted  as  a  ball  valve  for  3'ears.  The  uterus  had 
been  repeatedly  examined  before,  but  nothing  could  be  discovered. 

Physical  Signs. — These  will  depend  in  great  degree  upon  the  size 
and  location  of  the  growth.  Should  it  be  in  the  cavity  of  the  body, 
and  small,  no  signs  will  be  afforded  by  the  touch  or  speculum,  and 
the  uterine  sound  will  give  no  evidence  of  its  presence.  The  cavity 
will  be  discovered  to  be  much  congested,  and  a  copious  flow  of 
lilood  will  often  follow  the  withdrawal  of  the  instrument.  Should 
the  tumor  be  large,  the  uterus  will  often  be  found  to  be  displaced, 
and  increased  in  size,  and  the  cervix  somewhat  dilated.  Should 
the  attachment  of  the  tumor  be  cervical,  it  can  often  be  felt  hang- 
ing from  the  canal  or  in  the  os  uteri.  But  no  examination  for 
uterine  polypi  can  be  considered  complete  until  the  cervix  has  been 
tully  dilated  by  tents,  and  careful  exploration  been  made  by  touch. 


534  .  UTERINE    POLYPI. 

Even  then  a  number  of  attempts  will  often  be  requisite  before  very 
small  growths  are  detected. 

Differentiation. — Polypi  must  be  differentiated  from  fibrous 
tumors  even  after  the  discovery  of  an  intra-uterine  growth  has 
been  made.  The  symptoms  to  which  these  affections  give  rise  are 
very  similar,  and  it  is  by  physical  means  alone  that  differentiation 
can  be  effected.  These  means  are  the  use  of  tents,  the  sound,  and 
touch.  By  them,  the  mobility  of  the  tumor,  the  point  of  its  attach- 
ment, and  the  breadth  of  its  base,  may  usually  all  be  determined. 

Course  and  Termination. — Nature  may  cure  a  uterine  polypus  by 
ejecting  the  mass  with  so  much  force  as  to  fracture  its  attachment 
and  disconnect  it  from  the  uterus ;  or  calcification,  fatty  degenera- 
tion, ulceration,  or  sloughing  may  occur.  But  none  of  these 
results  can  be  looked  for  with  any  confidence.  In  the  majority  of 
instances,  without  surgical  interference,  steadily  advancing  ansemia 
will  ultimately  destroy  life. 

Prognosis. — The  prognosis  is  generally  good,  depending,  of  course, 
upon  the  possibility  of  removal. 

Complications. — Polypi,  if  so  small  as  not  to  greatly  increase  the 
weight  of  the  uterus,  create  but  two  complications,  leucorrhoea  and 
metrorrhagia,  which  may  go  on  to  the  production  of  fatal  anaemia. 
If  they  be  so  large  as  to  increase  the  size  and  weight  of  the  uterus, 
displacements,  with  their  attendant  irritation  of  rectum  and  blad- 
der, may  show  themselves,  and  even  inversion  has  been  known  to 
occur. 

Treatment. — This  may  be  cither  palliative  or  curative,  and  it  is 
as  necessary  for  the  practitioner  to  familiarize  himself  with  one  as 
with  the  other.  Many  a  patient  suffering  from  intra-corporeal 
polypus  has  had  life  cut  short  by  intemj)erate  efforts  at  its  removal, 
who  by  a  systematic  and  patient  course  of  palliative  treatment 
might  not  only  have  lived  for  years  but  have  ended  her  disease  by 
expelling  the  tumor  into  the  vagina  and  rendering  it  accessible  to 
safe  removal.  There  are  few  men  of  large  experience,  who  cannot 
recall  such  instances  of  the  unfortunate  results  of  injudicious 
l^ractice,  either  in  their  own  experience  or  that  of  others.  The 
dictum  of  Gooch  that,  "  when  hemorrhages  from  the  uterus  arise 
from  a  polypus,  medicines  are  useless.  The  only  effectual  way  to 
cure  the  hemorrhages  is  to  remove  the  polypus,"  is  undeniably  sound. 
Lives  have,  however,  been  sacrificed  to  just  such  a  style  of  assertion 
both  in  this  and  other  diseases.  "When  the  young  practitioner  reads 
the  brilliant  record  of  an  os  dilated,  an  instrument  carried  to  the 
fundus,  a  tumor  removed,  and  a  case  of  metrorrhagia  cured,  he  feels 


TREATMENT.  535 

almost  culpable  if  lie  have  a  case  under  treatment  and  do  not  follow 
a  similar  course,  and  as  he  sees  his  patient's  pale  face  every  day 
demanding  a  cure,  he  is  often  hurried  into  a  resolve  to  run  every 
risk  to  effect  one.  But  he  who  is  familiar  with  this  kind  of 
}iractice  knows  that  it  in  reality  involves  many  dangers,  and  that 
-uccessful  cases  have  a  proneness  for  creeping  into  literature  which 
does  not  characterize  fatal  issues. 

I  would  be  distinctly  understood,  as  not  undervaluing  the  prac- 
tice of  dilating  the  cervix  and  removing  intra-corporeal  polypi  by 
instruments  carried  to  the  fundus.  I  merely  desire  to  insist  upon 
the  fact  that  such  a  course  is  necessarily  dangerous;  that  it  should 
1  )e  undertaken  only  after  careful  consideration  ;  and  that  its  proper 
jierformance  requires  skill  and  experience. 

Whenever  it  is  practicable  to  do  so,  all  manipulation  should  be  de- 
layed  until  expulsion  of  the  tumor  into  the  vagina  is  accomplished ; 
l)ut,  unfortunately,  operative  procedure  is  often  called  for  before 
this  can  be  effected.  Then  the  operator  has  no  choice.  lie  is  forced 
to  proceed  to  removal  of  the  growth  even  at  a  disadvantage  and 
at  a  risk  to  his  jDatient.  If  the  os  internum  be  fully  dilated,  the 
opening  of  the  external  os  will  not  jjrove  difficult  of  accomplish- 
ment. Slitting  the  neck  or  dilating  it  will  usually  be  sufficient  to 
bring  the  growth  within  reach  of  a  tenaculum  which  will  draw  it 
forth.  But  where  both  are  to  be  opened  danger  is  involved  in  the 
l>rocess,  for  not  only  are  we  called  upon  to  assume  that  connected 
with  and  dependent  upon  the  use  of  tents ;  we  have  to  do  so  in  a 
})athological  condition  peculiarly  liable  to  be  complicated  by  endo- 
metritis and  pelvic  peritonitis.  I  have  seen  several  deaths  due  to 
tliese  efforts,  and  I  always  inaugurate  them  with  a  certain  amount 
of  anxiety. 

Palliative  Treatment. — As  I  have  said  a  great  deal  in  connection 
with  the  treatment  of  submucous  fibroids,  which  would  have  to 
be  repeated  here  if  I  went  into  the  detailed  consideration  of  this 
subject,  I  shall  limit  myself  to  a  concise  recapitulation. 

1st.  Replace  the  uterus  if  it  be  displaced,  and  keep  it  in  position 
l>y  means  of  an  appropriate  pessary,  at  the  same  time  that  all  pres- 
sure is  taken  from  the  fundus  by  avoidance  of  tight  clothing  and 
all  violent  muscular  efforts,  and  by  the  use  of  skirt  and  abdominal 
supporters. 

2d.  Keep  the  patient  in  bed  at  menstrual  periods,  urging  her  to 
avoid  warm  drinks,  and  to  use  cold  and  acid  ones.  Give  cannabis 
indica,  opium,  gallic  acid,  ergot,  or  elixir  of  vitriol  during  the 
periods.     After  a  menstrual  epoch  has  lasted  four  or  five  days, 


536  UTERIXE    POLYPI. 

use  a  tampon  saturated  with  solution  of  alum  or  tannin,  removing 
it  immediately  if  there  be  any  evidence  of  regurgitation  through 
the  tubes. 

3d.  Keep  the  bowels  regular,  and  avoid  fatigue  and  over-exertion 
at  all  times. 

4th.  Repair  the  damage  done  to  the  blood  by  nutritious  food, 
and  that  done  to  the  nervous  system  by  bitter  tonics  and  nervines, 
avoiding  the  use  of  iron  which  increases  the  tendency  to  hemor- 
rhage. 

5th.  During  the  inter-menstrual  periods  give  ergot  freely,  to 
favor  extrusion  of  the  growth. 

•Curative  Tixatment. — There  are  three  positions  in  which  a  polypus 
may  be  found :  above  the  contracted  os  internum,  above  the  con- 
tracted OS  externum,  or  in  the  vagina.  The  first  position  presents 
the  gravest  difiiculties  in  the  management  of  these  cases,  the 
second  presents  nmch  less  serious  difficulties,  while  the  third  may, 
with  our  i:)resent  appliances,  be  almost  said  to  present  none. 

If  it  be  discovered  that  the  cervical  canal  has  been  dilated  by 
the  weight  and  wedge-like  action  of  the  polypus  aided  by  uterine 
contraction,  the  walls  of  the  cervix  may  be  slit  on  each  side  nearly 
to  the  vaginal  junction,  and  a  tenaculum  or  vulsellum  fixed  in  the 
tumor  by  wdiich  it  may  be  drawn  out  of  the  uterus.  Or  by  means 
of  tents  the  resisting  os  may  be  dilated  so  as  to  admit  the  smallest 
size  of  Molesworth's  dilator,  and  by  this  further  expansion  may  be 
eftected.  After  this,  if  the  tumor  can  be  eeized,  it  may  be  drawn 
out,  or  ergot  in  full  doses  may  be  given  to  cause  its  expulsion. 
If  it  be  found  necessary  to  seek  the  pedicle  at  or  near  the  fundus, 
it  may  be  severed  by  the  same  means  which  we  adopt  in  case  the 
tumor  hang  in  the  vagina,  namely — 

Excision ; 

Torsion  and  traction ; 

Ecrasement ; 

The  galvano-caustic  wire. 

Should  the  pedicle  be  within  reach  of  knife  or  scissors,  it  may 
be  divided ;  or  if  higher  in  the  uterus,  the  polyptome  (Fig.  154) 
may  be  employed.  Should  the  growths  be  so  small  as  not  to  be 
susceptible  of  seizure,  they  may  be  scraped  from  their  attachment 
by  a  large  steel  curette;  and  should  they  be  small  and  possess 
slender  pedicles,  they  may  be  seized  with  forceps  and  twisted  off. 
Should  they  be  so  small  and  slippery  as  to  defeat  this  plan,  or  should 
they  be  numerous,  or  return  very  soon  after  removal,  the  cervix 


TREATMENT, 


5a7 


should  be  slightly  dilated,  cleansed  of  mucus  and  blood,  and 
thorouo^hlj  painted  over  by  fuming  nitric  acid,  as  recommended 
by  Dr.  Lombe  Athill  in  disease  of  the  lining  membrane. 


Fig.  154. 
G.  t/£:mann  &.C0. 


Simpson's  polyptome. 


The  ligature,  lately  so  popular,  is  now  rarely  employed  the 
tardiness  of  its  action,  and  the  fetid  discharge  which  it  excites, 
rendering  it  objectionable  and  dangerous.  Ecrasement  constitutes 
the  safest  and  most  expeditious  of  all  the  operations.  Sometimes, 
however,  great  difficulty  attends  the  encircling  of  the  tumor  by 
the  chain  of  the  instrument.  To  effect  this,  it  is  often  necessary 
to  encircle  the  mass  first  by  means  of  a  ligature  passed  by  Gooch's 
eanulse,  and  then  to  draw  the  chain  into  position  by  tying  it  to 
the  end  of  this,  as  represented  in  the  chapter  on  fibroids.  Under 
these  circumstances  Hicks's  wire  rope  ecraseur  (Fig.  155)  consti- 
tutes an  excellent  substitute.  The  polyptome  of  Simpson  or  that 
of  Aveling  often  answers  a  good  purpose  in  these  cases. 


Fig.  155. 


G.TIEMANN  &.C0. 
Hicks's  wire  rope  ecraseur. 


When  the  polypus  is  of  hard,  fibrous  character,  and  fills  the 
uterus  so  completely  that  the  pedicle  cannot  be  reached,  those 
[lortions  which  are  within  reach  may  be  cut  away  piecemeal  by 
Nulaton's  forceps,  constructed  for  this  purpose,  or  by  ordinary 
lurved  scissors.  Dr.  Gooch  long  ago  announced  that  when  a  liga- 
ture was  applied  around  one  of  these  growths,  that  part  above  as 
well  as  below  its  constriction  often  died.  It  is  with  a  hope  of  such 
a  result  that  we  make  use  of  this  means.  I  have,  however,  cut 
through  the  centre  of  a  fibrous  polypus  and  found  the  attached 
portion  continue  to  flourish  as  before  operation. 

When  a  large  fibrous  polypus  presents  its  pedicle  in  such  a  way 


538  UTERINE    POLYPI. 

that  it  can  be  encircled  by  the  galvano-caustic  wire,  this  instru- 
ment should  be  employed.  It  not  only  cuts  without  the  applica- 
tion of  force  through  the  hardest  tissue,  but,  being  brought  to  a 
white  heat  by  the  electric  current  which  passes  through  it,  it  sears 
the  open  vessels,  checks  hemorrhage,  and  prevents  septicaemia. 

Should  a  very  large  fibrous  polypus  have  escaped  from  the  ute- 
rine cavity  in  whole  or  in  part,  it  may  be  dealt  with  by  the  follow- 
ing methods.  A  pair  of  long  obstetric  forceps  may  be  applied  to  it, 
and  by  means  of  these  it  may  be  delivered  as  a  child's  head  is.  If 
the  perineum  obstruct  its  escape,  this  may  be  severed  by  a  bistoury 
and  sewed  up  after  the  operation.  If  the  tumor  cannot  be  delivered 
in  this  way,  the  lowest  portions  may  be  cut  away  by  scissors,  and 
the  base  if  it  bleed  too  freely  be  seared  b}-  the  actual  cautery,  or  it 
may  be  cut  away  piecemeal  by  the  galvano-cautery. 

In  conclusion,  I  offer  a  resume  of  the  methods  of  treatment  re- 
commended in  this  chapter. 

1st.  If  a  polypus  exist  in  utero  and  the  cervical  canal  be  firmly 
closed,  avoid  immediate  attempts  at  its  removal  unless  the  symp- 
toms be  so  grave  as  to  make  that  course  advisable.  Temporize  by 
employing  palliative  means  until  dilatation  of  tlie  cervix  and  per- 
haps expulsion  of  the  growth  into  the  vagina  are  effected. 

2d.  To  facilitate  expulsion,  dilate  by  tents  or  incise  the  walls  of 
the  cervix  laterally  and  use  ergot  steadily,  either  internally  or 
hypodermically. 

3d.  If  the  OS  internum  be  fully  dilated,  remove  the  polypus  at 
once,  for  the  operation  is  one  attended  by  little  danger  even  if  the 
cervix  requires  incision. 

4th.  If  the  cervix  be  dilated  and  the  tumor  be  in  utero,  seize  it 
with  a  vulsellum  at  its  lowest  extremity,  and  make  a  cautious  but 
rapid  attempt  at  its  removal  by  torsion  and  traction.  Lengthy 
manipulations  carried  on  in  utero  are  always  very  hazardous. 

5th.  If  it  cannot  be  removed  in  this  way,  slide  up  along  the  wall 
of  the  tumor,  upon  which  steady  traction  is  made,  Hicks's  ^cra- 
seur  or  a  pair  of  sharply  curved  scissors,  and  sever  the  stem. 


SARCOMA  OF  THE  UTERUS.  539 


CHAPTER    XXXIV. 


SARCOMA  OF  THE  UTERUS. 


History. — Scattered  through  medical  literature  may  be  found 
descriptions  of  a  tumor  growing  from  the  cavity  of  the  uterus, 
which  appears  to  occupy  a  middle  ground  between  myo-fibroma  on 
the  one  hand  and  true  cancer  on  the  other.  Presenting  in  many 
respects  the  ordinary  physical  aspects  of  benign  fibroid  growths 
in  their  early  periods,  these  tumors  demonstrate  a  marked  tendency 
to  return  after  ablation.  Even  after  repeated  and  thorough  removal, 
they  again  and  again  recur,  and  in  many  cases  their  real  character 
is  in  this  way  discovered.  Another  peculiar  and  dangerous  charac- 
teristic, which  marks  their  difterence  from  benign  fibroids,  consists 
in  their  tendency  to  throw  out  fungoid  growths,  which  show  a 
marked  tendency  to  undergo  molecular  death  and  disappear  by 
ulceration,  which  process  saps  the  vital  forces  of  the  patient  by 
repeated  and  prolonged  hemorrhages,  and  by  opening  the  mouths 
of  absorbent  vessels  for  the  entrance  of  septic  elements  into  the 
blood. 

The  clinical  features  of  such  growths  will  be  found  recorded  in 
English  literature  by  Callender,^  Ilutchinson,^  Oldham,^  and  West,* 
to  whose  interesting  accounts  the  reader  is  referred.  Of  course 
pathologists  were  struck  by  these  two  facts  in  connection  with  such 
tumors :  first,  their  marked  tendency  to  return  after  ablation,  and 
second,  the  absence  of  micrographie  evidences  of  cancer  in  patho- 
logical developments  showing  many  of  the  features  of  malignancy. 
Paget  grouped  them  under  three  heads,  malignant  fibrous  tumors, 
recurrent  fibroids,  and  myeloid  tumors,  while  Lebert  described  them 
under  the  name  of  fibro-plastic  tumors,  and  Rokitansky  under  that 
of  fasciculated  cancer.  Not  until  the  time  of  Virchow  were  they 
described  under  the  old  and  previously  loosely  applied  term  of 
sarcoma.  This  pathologist  clearly  defined  the  disease  and  placed 
it  in  a  distinct  class,  apart  from  developments  somewhat  similar  in 


'  Pathological  Transactions,  vol.  ix.  ^  Ibid.,  vol.  viii. 

'  Wilks,  Pathological  Anatomy,  p.  404.  *  Op.  cit ,  art.  Recurrent  F'ibroid. 


540  SARCOMA    OF    THE    UTERUS. 

clinical  features,  but  some  of  wliicli  were  entirely  benign  and  others 
truly  cancerous. 

Definition,  Frequency,  and  Synonyms. — "  Sarcoma,"  says  Virchow, 
"is  for  me  a  production  easily  definable.  I  mean  by  it  a  growth  the 
tissue  of  which,  following  the  general  group,  belongs  to  the  con- 
nective tissue  series,  and  which  is  distinguishable  from  marked 
varieties  of  the  groups  of  connective  tissues  only  by  the  predomi- 
nant development  of  cellular  elements." ^  They  possess,  he  declares, 
the  characters  of  incomplete,  rudimental,  or  embryonic  development, 
and  not  those  of  perfect  tissue.  This  peculiarity  existing  in  the 
original  tumor  becomes  more  and  more  marked  as  recurrence  takes 
place  after  successive  removals. 

Were  I  to  draw  my  deductions  from  my  own  experience,  I  would 
say  that  sarcoma  of  the  uterus  was  not  very  rare.  JVIany  cases 
which  have  been  regarded  as  cancer,  and  not  a  few  of  supposed 
fatal  fibroid  tumor  or  polypus,  have  been  unquestionably  of  thia^ 
aftection.  Virchow,^  however,  expresses  a  different  opinion.  "The 
production  of  sarcoma  on  the  mucous  lining  of  the  uterus,"  says 
he,  "is  often  spoken  of,  and  even  in  his  first  work  Lebert  describes 
a  fibro-plastic  polypus.  Nevertheless  from  my  observation  sarcoma 
is  very  rare  at  this  point,  and  the  majority  of  tumors  described  as 
such  are  of  a  simply  hyperplastic  nature.  True  sarcoma,  however, 
does  originate  in  the  uterine  mucous  membrane  in  medullary  form 
difiicult  of  recognition,  often  very  soft,  and  with  round  cells,  some- 
times with  all  the  characteristics  of  myo-sarcoma;  the  tissue  may 
become  in  places  more  compact,  and  may  form  larger  masses,  and 
attain  a  degree  of  firnniess  so  great  that  I  have  seen  the  best  diag- 
nosticians deceived  as  to  the  nature  of  the  aftection,  and  take  it  for 
a  fibroid."  Before  my  attention  was  especially  called  to  this  subject 
within  the  last  three  years,  I  confounded  such  cases  with  medullary 
cancer.  Since  that  time  I  have  met  with  four  cases  wliich,  both 
from  clinical  and  microscopic  evidence,  I  am  forced  to  regard  as 
sarcomatous  developments.  None  were  confounded  with  simple 
hyperplastic  growths  as  A^irchow  suggests,  for  all  ended  fatally. 

Pathology. — Pathologists  have  conmionly  confounded  sarcoma  of 
the  uterus  with  cancer.  The  reasons  for  this  are  probably  these: 
after  the  former  begins  to  ulcerate,  it  resembles  the  latter  in  many 
clinical  features,  both  have  a  marked  tendency  to  return,  and  they 

'  Pathol,  des  Tumeurs,  par  R.  Virchow,  traduit  par  P.  Aronsohn,  vol.  ii.  p.  173. 
"  Op.  cit.,  vol.  ii.  p.  344. 


CAUSES.  541 

sometimes  unite  in  the  same  tumor.  The  time  has  certainly  arrived, 
however,  wJien  they  should  be  separated  both  clinically  and  patho- 
logically. 

Of  lute  years  uterine  sarcoma,  as  a  disease  apart  from  cancer,  has 
received  careful  study  in  Germany,  excellent  reports  of  cases  being 
furnislied  by  i\hlfield,  Hegar,  Winckel,  Gusserow,  Spiegelberg,  and 
others. 

Unlike  myo-iibromata,  sarcomatous  tumors  have  no  capsules,  but 
are  immediately  connected  with  the  uterine  connective  tissue. 
Virchow  declares  that,  "  in  accordance  with  their  density,  sarcomata 
may  be,  like  all  morbid  tissues,  divided  into  two  groups:  soft  and 
hard  sarcomata."  As  the  disease  consists  merely  in  a  multiplication 
of  normal  cells,  homologous  to  the  tissue  in  which  it  grows,  and 
subject  to  no  other  disorder  than  h^-pertrophy,  it  is  chai'acterized 
liy  one  of  the  cells  typical  of  the  connective  tissue  group.  Thus 
we  may  have  spindle,  round,  and  stellate  celled  sarcoma,  the  second 
being  the  most  frequent,  and  the  first  the  rarest  in  the  uterus.  In 
some  cases  the  cells  are  so  large  as  to  cause  the  name  "giant-celled'" 
to  be  given  to  the  growth.  "  We  may,"  says  Virchow,  "-divide  all 
sarcomata,  and  not  simply  those  rich  in  cells,  into  two  groups:  the 
one  with  large,  and  the  other  with  small  cells."  These  cells  are 
merely  exaggerated  reproductions  of  those  of  the  mother  tissue, 
and  "behave  like  cells  of  parenchyma,  not  like  surface  cells  (epi- 
thelium, cancer),"  which  are  heteroplastic  to  the  mother  tissue. 
Between  these  cells  the  intercellular  substance  is  ahvays  preserved, 
while  in  cancer  we  find  cells  of  epithelial  type  pressed  closely 
together  in  alveoli  formed  of  trabeculse  created  by  coimective  tissue. 

Sarcoma,  usually  primary,  is  sometimes  engrafted  upon  myo- 
fibroma by  the  process  styled  metaplasia,  and  a  true  sarcomatous 
tumor  may  itself  be  affected  by  cancer.  Sarcomata  into  which  a 
great  deal  of  fibrous  tissue  enters  are  dense,  like  myo-fibroma, 
and  Ilegar^  admits  a  transition  form,  a  fibro-  and  myo-sarcoma. 

These  growths  are  so  rich  in  vessels  that  Virchow  declares  that 
this  feature  is  characteristic  of  them.  To  this  vascularity  is  due 
their  tendency  to  give  forth  a  watery  flow^,  to  bleed  freely,  and  to 
absorb  septic  materials. 

Cauftes. — With  reference  especially  to  uterine  sarcoma  little  can 
with  positiveness  be  said  on  this  point.  Virchow  alludes,  in  speak- 
ing of  sarcoma  in  general,  to  injuries,  youth  and  old  age,  primitive 
debility  in  the  part  affected,  inflammations,  etc. ;  but  whether  ute- 
rine sarcoma  has  ever  been  traced  to  these  I  do  not  know. 

'  Archiv  fiir  Gynakologie,  ii.  1,  1871 


642  SARCOMA    OF    THE    UTEEUS. 

Symptoms. — These  may  be  thus  presented : 

Pain; 

Menorrhagia  or  metrorrhagia ; 

Offensive  mucous  discharge; 

Pinkish  watery  discharge ; 

Discharge  of  shreds  or  portions  of  the  tumor; 

Pressure  on  rectum  and  bladder; 

Uterine  tenesmus ; 

Constitutional  depreciation. 
Gusserow  declares  tliat  pain  is  constant  and  early,  but  Hegar 
denies  this.     My  experience  would  lead  me  to  endorse  the  opinion 
of  the  latter,  though  I  have  seen  it  very  severe. 

Physical  Signs. — These  will  depend  to  a  certain  degree  upon  the 
individual  peculiarities  of  the  case.  Sarcoma  invariably  develops 
in  the  cavity  of  the  uterus.  Only  one  case  has  been  reported,  (by 
Veit,)  in  which  the  cervix  was  primarily  affected.  The  growth 
usually  arises  from  the  uterine  wall  by  a  broad  base  and  projects 
into  the  cavity.  In  time,  uterine  contractions  dilate  the  cervix, 
and  a  jiortion  of  the  mass  is  forced  into  the  vagina. 

In  rare  cases  sarcoma  assumes  a  jiolyjioid  form,  and  in  others, 
coincidently  with  the  uterine  development,  an  extra-uterine  growth 
projects  into  Douglas's  pouch  or  one  iliac  fossa.  Another  way  in 
which  sarcoma  affects  the  uterus  is  by  diffuse  infiltration  into  one 
or  both  walls.  This  may  affect  mucous  or  submucous  tissues  alone, 
or  even  the  muscular  structure  itself.  This  surface  soon  ulcerates 
and  gives  forth  a  fetid  discharge.  In  some  cases  this  diffuse  infil- 
tration may  affect  the  whole  uterus,  giving  it  the  appearance  of 
symmetrical  enlargement. 

If  the  tumor  can  be  touched,  it  is  usually  found  to  be  soft, 
spongy,  and  friable,  though  in  some  cases  it  is  hard  and  firm  like 
myo-fibroma.  By  conjoined  manipulation  the  uterus  is  found  to 
be  large  and  usually  irregular  in  shape  as  if  the  seat  of  fibroid 
tumors.  The  uterine  sound  indicates  enlargement  of  this  organ. 
It  is  very  common  for  the  cervix  to  be  dilated  and  portions  of  the 
mass  to  be  expelled. 

Differentiation. — Although  these  symptoms  and  physical  signs 
will  strongly  point  to  the  existence  of  sarcoma,  the  microscope 
alone  will  distinguish  it  from  cancer,  myo-fibroma,  and  simple 
hyperplastic  growths. 

Course^  Duration^  and  Termination. — It  runs  a  much  slower  course 
than  true  cancer ;  a  much  more  serious  one  than  fibroids  and 
hyperplastic  growths.     In  rare  cases  it  terminates  rapidly,  but  it 


i< 


CANCER  OF  THE  UTERUS.  543 

lias  frequently  been  known  to  last  for  five  or  six  years.  The  patient 
gradually  sinks  under  the  following  morbid  influences:  hemorrhage, 
septicaemia,  spread  of  the  disease  to  neighboring  abdominal  viscera, 
disturbances  of  nutrition,  or  peritonitis. 

Prognosis. — This  is  invariably  unfavorable;  a  fatal  issue  is  a 
question  merely  of  time,  whether  the  growth  be  removed  or  left 
iininterfered  with. 

The  microscope,  to  a  certain  extent,  aids  us  in  predicting  the 
probable  rapidity  of  the  aftection.  The  more  nearly  it  approaches 
a  hard  growth,  the  prej^onderating  element  of  which  is  fibrous 
tissue,  tlie  slower  will  be  its  course ;  the  more  it  partakes  of  a  soft 
character  and  shows  itself  rich  in  cellular  elements,  the  more  rapid 
will  be  its  progress  in  molecular  death.  Again,  the  small-celled 
varieties  show  a  more  marked  tendency  to  rapidity  of  production 
than  those  which  are  characterized  by  large  cells. 

Treatment. — If  the  cervix  be  dilated,  and  a  sessile  growth  be 
discovered  in  the  uterine  cavity,  it  should  be  entirely  removed  by 
galvano-cautery,  ^crasement,  excision,  or  the  curette,  and  the  base 
of  the  growth  thoroughly  cauterized  with  chemically  pure  nitric 
acid  or  some  equally  powerful  caustic.  If  the  cervix  be  not  dilated, 
this  may  be  accomplished  by  the  use  of  tents,  and  the  disease 
attacked  by  surgical  means. 


CHAPTER    XXXV. 


CANCER  OF  THE  UTERUS. 


Definition. — Between  cancer  of  the  uterus  and  the  same  aiFection 
in  other  parts  of  the  system  there  are  no  marked  difterences.  As 
in  other  organs,  it  may  be  defined  as  a  disease  which  is  characterized 
by  great  proliferation  of  connective  tissue,  excessive  generation  of 
cells  of  epithelial  type,  and  marked  tendency  to  extension  to 
neighboring  parts,  to  molecular  death,  and  to  return  after  removal. 
Waldeyer^  concisely  defines  cancer  as  "an  atypical,  epithelial 
neoplasm." 


'  Billroth,  Surg.  Path.,  Am.  ed. 


544  CANCER  OF  THE  UTERUS. 

History. — M.  Becquerel  asserts  that,  "  in  spite  of  its  great  fre- 
quency, cancer  of  the  uterus  is  not  a  disease  of  which  the  history 
has  been  long  known."  That  it  was  not  understood  as  we  under- 
stand it  to-day,  is  most  true  ;  but  the  ancients  surely  had  a  certain 
degree  of  knowledge  concerning  its  clinical  features.  Hippocrates 
-de  Morbis  Mulierum— describes  it  at  length,  declaring  it  to  be 
incurable.  Archigenes  wrote  a  chapter  upon  it,  describing  the 
ulcerated  and  non-ulcerated  forms  and  the  peculiarities  of  the 
discharges.  His  article  is  preserved  by  Aetius,  who  entitles  it, 
"  De  Cancris  Uteri,"  and  is  copied  verbatim  by  Paul  of  vEgina 
without  the  slightest  acknowledgment.  The  Arabians  likewise 
were  familiar  with  it,  Alsaharavius,  Haly  Abbas,  and  Rhazes  all 
alluding  to  its  prognosis  and  treatment  in  a  manner  which  leads 
us  to  believe  that  they  understood  its  true  nature. 

Upon  the  revival  of  gynecology  in  France,  the  disease  was  con- 
founded with  fibrous  tumors  and  areolar  hyperplasia.  Astruc 
described  "scirrhus"  as  the  result  of  abortion,  in  1766,  and  the  con- 
fusion which  attached  to  his  description  extended  long  after  him. 
It  characterized  the  times  of  R^camier  and  Lisfranc,  and  even  sc 
late  as  our  own  period  we  see  the  view  indorsed  by  Asliwell, 
Montgomery,  Duparcque,  and  many  others.  Blatin  and  Nivet,^  in 
expressing  their  belief  that  scirrhus  results  from  chronic  inflanmia- 
tion  of  the  parenchyma,  append  the  following  footnote:  "  Paul  of 
^gina,  Galen,  Andral,  Broussais,  Breschet  and  Ferrus,  Piorry, 
Bouillaud,  etc.,  place  scirrhus  among  the  terminations  of  chronic 
inflammation ;  some  of  them,  however,  admit  the  existence  of  a 
predisposition."  Although  it  was  known  to  the  physicians  of  the 
most  ancient  times,  we  are  indebted  to  them  for  little  in  connection 
with  it,  except  portions  of  the  imi^erfect  nomenclature  which  now 
attaches  to  it.  It  is  beyond  question  that  within  the  last  half 
century  much  more  has  been  accomplished  for  the  thorough  under- 
standing of  the  subject  than  ever  has  been  done  at  any  former  time, 
and  yet,  even  now,  much  doubt  and  uncertainty  exist  as  to  its 
varieties,  and  its  pathological  characteristics. 

Pathology. — With  regard  to  the  jtathology  of  cancer  the  views 
of  pathologists  have,  of  late,  undergone  considerable  modifica- 
tion. Formerly,  the  prevailing  opinion  was  that  it  was  always 
the  local  manifestation  of  a  general  blood  state.  At  present, 
opinion  is  divided;  many  still  adhering  to  the  old  view,  while 
others  are  yielding  to  the  cogent  reasoning  of  those  who  regard 

'  Mai.  des  Femmes,  Paris,  1842. 


PATHOLOGY.  545 

it  as  originally  a  local  affection,  one  of  the  most  striking  features 
of  wliicli  is  a  tendency  rapidly  to  intoxicate  the  system.  In  an 
exceedingly  able  and  interesting  discussion  upon  this  subject  be- 
fore the  London  Pathological  Society  in  March,  1874,  the  former 
of  these  views  was  maintained  by  Messrs.  DeMorgan,  Hutchinson, 
Moxon,  Arnott,  and  others  ;  the  latter  by  Sir  James  Paget,  Sir  W. 
Jonner,  Dr.  Greenhow,  and  others.  So  equally  was  the  society  di- 
vided in  opinion  that  a  commentator  remarks  that  "  in  point  of 
numbers  the  constitutionalists  almost  equalled  the  localists.' 

Whatever  be  the  peculiar  state  which  gives  rise  to  cancerous 
deposit,  it  is  certain  that  any  form  of  the  affection  may  arise  from 
one  and  the  same  disorder.  This  is  proved  by  the  facts  that 
several  deposits  of  different  varieties  may  coincidently  exist,  that 
one  form  may  change  into  another,  and  that  one  being  removed 
by  surgical  means  a  different  one  may  replace  it. 

As  there  is  doubt  as  to  the  origin  of  cancer,  so  is  there  as  to  the 
method  in  which  the  local  deposit  takes  place.  Certain  patholo- 
gists, of  whom  M.  Eobin,  of  Paris,  may  be  taken  as  a  representa- 
tive, believe  that,  under  the  influence  of  a  constitutional  vice, 
which  exerts  a  baneful  influence  over  nutrition  and  formation, 
a  fluid  blastema  is  transmitted  from  the  blood  into  the  connective 
tissue  of  the  part.  From  this  molecules  arrange  themselves  and 
form  the  anatomical  elements  of  cancer.  Another  party,  of  which 
Virchow'  was  the  founder,  maintains  that  the  proliferation  of  con- 
]  nective  tissue  and  hypergenesis  of  cells  both  arise  from  repeated 
subdivision  of  connective  tissue  corpuscles.  These  go,  some  to 
creation  of  tissue,  some  to  filling  brood-spaces,  and  others  to  forma- 
tion of  epithelium.  Still  another  party,  headed  by  Remak^  and 
Waldeyer,^  hold  that  all  cancerous  disease  in  the  uterus  takes  its 
origin  from  the  epithelium  lining  glands  which  dip  into  the 
parenchyma.  The  cancer  cells  are  due  to  perverted  action  of  normal 
epithelial  production,  while  the  stroma  comes  from  proliferation  of 
the  interstitial  substance  or  connective  tissue  of  the  part.  "  Only 
Thiersh,  and  recently  Waldeyer,"  says  Billroth ,2  "maintain,  as  I 
do,  the  strict  boundarj'^  between  epithelial  and  connective  tissue 
cells.  ...  I  only  call  those  tumors  true  carcinomata  which 
have  a  formation  similar  to  that  of  true  epithelial  glands  (not  the 

'  See  an  able  and  interesting  r4snm4  on  this  subject  in  the  N.  Y.  Med.  Journ.  for 
September,  18(i9,  by  Prof.  W.  T.  Lusk,  M.D.,  to  which  I  am  much  indebted. 
*  Surg.  Pathol.,  Am.  ed.,  p.  627. 
35 


546  CANCER  OF  THE  UTERUS. 

lymphatic  glands),  and  whose  cells  are  mostly  actual  derivatives 
from  true  epithelium." 

If  the  cervix  uteri  has  been  first  affected,  the  disease  spreads  from 
this  point,  invades  the  whole  neck,  and  sometimes  the  body  of  the 
uterus,  the  ovaries,  vagina,  bladder,  and  intermediate  tissue.  Even 
the  bones  of  the  pelvis  may  be  attacked.  For  a  varying  length  of 
time  the  deposition  goes  on,  then  without  assignable  cause  the 
lowly  organized  mass  begins  to  die,  and  ulceration  or  molecular 
death  occurs.  The  detritus  gives  rise  to  a  fetid,  ichorous,  and 
bloody  discharge,  which  excoriates  the  vulva  and  thighs,  and 
renders  the  patient  disagreeable  to  herself  and  all  around  her. 

The  disease  extends  to  neighboring  and  distant  organs  by  several 
methods :  first,  by  continuous  growth ;  second,  bj'  absorption  of 
contagious  fluid  or  cell  elements  from  the  cancer  by  the  lymphatics 
and  transmission  to  the  glands  and  other  parts ;  and  third,  by 
venous  absorption. 

^  Varieties. — Cancer  may  attack  the  uterus  in  any  one  of  the  fol- 
lowing forms : 

1st.  Scirrhus;  fibrous,  or  chronic  cancer; 

2d.  Encephaloid;  or  acute  cancer; 

3d.  Epithelioma;  cancroid,  or  epithelial  cancer. 

In  addition  to  the  varieties  of  cancer  thus  far  recorded,  a  fourth, 
the  colloid,  is  often  mentioned.  It  is  now  very  generally  regarded 
as  incorrect  to  look  upon  this  as  a  true  variety  of  cancer,  for  it  is 
rather  a  mucoid  degeneration  of  one  of  the  preceding  varieties. 
The  same  kind  of  degeneration  may  affect  other  growths  ;  and,  if 
the  mere  presence  of  colloid  matter  were  used  as  the  test  of  malig- 
nancy, many  errors  would  result.  Virchow  declares  in  reference 
to  this  important  point,  "you  may,  therefore,  say  colloid  cancer, 
colloid  sarcoma,  colloid  fibroma.  Here  colloid  means  nothing  more 
than  jelly-like."  When  this  change  has  affected  one  of  the  other 
varieties  of  cancer,  the  alveoli  are  found  very  large  and  filled  with 
jelly-like,  structureless  material. 

Cancerous  and  cancroid  affections  should  not,  with  the  light 
which  we  at  present  possess,  be  separated.  In  both  we  find  the 
characteristics  of  malignancy,  and  the  microscope  shows  the  same 

'  Although  to  be  systematic  I  have  deemed  it  best  to  adopt  these  conventional 
terms,  the  student  must  not  imagine  that  it  is  always  an  easy  matter  to  classify  a 
uterine  cancer  under  one  of  them.  Very  commonly  a  growth  will  be  met  with,  which 
occupies  a  middle  ground  between  these  varieties,  and  is  neither  pure  scirrhus,  en- 
cephaloid, nor  yet  epithelioma. 


FREQUENCY.  547 

type  of  cell  and  connective  tissue  structure.  It  is  certain,  too, 
that  the  physical  aspects  of  the  varieties  of  cancer  deiiend  merely 
upon  varying  proportions,  and  anatomical  arrangement  of  their 
component  parts.  Before  proceeding  then  to  the  details  of  this 
subject  let  me  premise  this  fact,  that  all  the  aifections  to  be  here 
treated  of,  whether  they  be  called  cancer,  cancroid,  or  epithelioma, 
are  really  malignant  in  character,  and  differ  as  to  malignancy  only 
in  degree ;  that  one  form  tends  to  pass  ra[)idly  into  another  of 
graver  type ;  and  that  in  all,  if  allowed  to  proceed  uninterfered 
with,  systemic  intoxication  is  only  a  question  of  time. 

Frequency. — Cancer  is  an  affection  of  frequent  occurrence,  and 
is  more  frequently  seen  in  the  uterus  than  in  any  other  organ. 
According  to  Rokitansky,^  the  following  average  scale  may  be 
adopted  as  representing  the  preference  of  cancer  for  various  organs. 
"  First  the  uterus,  the  female  breast,  the  stomach,  the  large  intes- 
tines, and  especially  the  rectum;  next  comes  cancer  of  the  lym- 
phatic glands,"  etc.  The  following  quotations  will  fully  display 
the  relative  frequency  of  cancer  of  the  uterus. 

Of  all  cuses  of  cancer  in  females,  the  uterus  is  affected  in  |,  Kiwisch.^ 
"  9118  "  "  "  "         was  "  2996,  Tanchou." 

"  8746  "  "  "  "  "  "  3000,  Simpson." 

"  5122  "  "  "  "  "  «  113,  Wagner.5 

Statistics  j)rove  that  cancer  is  nearly  three  times  more  frequent 
in  women  than  in  men,  and  more  than  three  times  more  frequently 
met  with  in  the  uterus  than  in  any  other  organ  of  the  female. 

Relative  frequency  of  the  varieties. — Virchow^  regards  cancroid 
aff*ections  as  constituting  the  majority  of  so-called  uterine  cancers. 
Hewitt''  declares  that  "the  form  of  cancer  usually  witnessed  in  the 
uterus  is  the  medullary  cancer.  The  'epithelial'  comes  next  in 
order  of  frequency."  Courty^  begins  his  remarks  upon  this  subject 
thus :  "  Epithelioma  of  the  vaginal  portion  of  the  neck,  perhaps  the 
most  frequent  of  uterine  cancers,"  etc. 

So  rare  is  it  to  meet  with  the  scirrhous  form  of  uterine  cancer 
that  some  writers  have  doubted  its  existence.  Rokitansky  admits 
the  possibility  of  its  occurrence,  but  regards  it  as  extremely  un- 

'  Sydenham  Trans.,  vol.  i,  p.  198,  Am.  ed.  ^  Klob,  op.  cit.,  p.  205. 

'  Rechi  sur  les  Tumeur  du  Sein,  p.  218.  ■•  Clin.  Lect.,  p.  42. 

*  New  York  Med.  Journ.,  vol.  ix.  p.  561. 

®  Lusk's  risumi.  N.  Y.  Med.  Journ..  Sep.  1869,  p.  567. 

^  Op.  cit.,  p.  575. 

^  Traite  prat,  des  Mai.  de  I'Uterus,  etc.,  p.  875. 


548  CANCER    OF    THE    UTERUS. 

common.  The  reason  of  this  is  the  fact  that  scirrhus  is  probably 
the  earliest  form  assumed  by  the  disease,  and  at  this  period  few 
symptoms  showing  themselves,  no  examination  is  sought  by  either 
physician  or  patient.  I  have  met  with  two,  and  I  think  three, 
undoubted  instances  of  it ;  to  the  history  of  one  of  which  I  shall 
make  allusion. 

Dr.  Treskatis  brought  to  my  clinique  at  the  College  of  Physicians 
and  Surgeons  a  woman  between  forty  and  tifty  years  of  age  who 
had  been  for  some  time  suffering  from  leucorrlioea  and  menorrhagia. 
Upon  examination  by  touch,  I  found  the  cervix  very  large  and 
exceedin«;ly  hard  and  resisting.  The  speculum  revealed  no  abrasion 
except  two  little  points  about  the  size  of  pin  heads,  which  bled 
freely  when  brushed  with  a  sponge.  From  the  facts  that  the  patient 
had  shown  no  previous  symptoms  of  uterine  disease  which  could 
have  resulted  in  areolar  hyperplasia,  that  there  was  no  intra- 
uterine cause  for  menorrhagia  discoverable,  and  that  the  hardness 
of  the  neck  was  excessive,  I  ventured  upon  the  diagnosis  of  scir- 
rhous cancer.  This  case  was  kept  under  observation  by  Dr.  Tres- 
katis, who  subsequently  reported  that  it  had  fully  developed  itself 
into  an  unquestionable  one  of  carcinoma,  as  evidenced  by  softening, 
ulceration,  the  microscoj)ic  signs,  etc.  Klob'  maintains  that  the 
disease  "in  the  majority  of  cases  occurs  in  a  fibrous  medullary  form, 
that  is,  in  the  rare  cases  in  which  we  are  enabled  to  recognize  and 
study  the  primary  condition  of  the  carcinomatous  growth  in  the 
dead  body,  we  find  that  form  which  is  described  under  the  name 
of  fibrous  carcinoma  or  scirrhus,  whilst  in  those  cases  in  which  the 
disease  proves  fatal,  we  generally  meet  with  the  distinct  medullary 
variety  of  carcinoma." 

After  the  first  or  hard  and  fibrous  stage  of  the  disease  has  lasted 
for  some  time,  prolific  generation  of  cells  occurs.  Tliese  fill  the 
alveolar  spaces  in  the  framework  of  connective  tissue,  which  spaces 
burst  and  communicate  with  each  other,  and  the  whole  mass  grows 
large  and  soft.  After  still  greater  growth,  these  overcrowded  cell 
spaces  open,  the  large  vessels  supplying  them  give  forth  blood 
freely,  and  ulceration  becomes  established.  As  this  last  stage  ad- 
vances, the  bladder  is  affected  by  an  extension  of  the  morbid 
matter  to  its  base.  Then  the  rectum,  the  lymphatic  vessels  and 
glands  of  the  pelvis,  and  the  neurilemma  of  the  sacral  nerves  may 
become  invaded,  and  the  morbid  action  spread  to  all  the  tissues 
of  the  pelvic  cavity.    The  frequency  with  which  different  parts  are 

•  Op.  cit.,  p.  192. 

1  i 


EPITHELIAL    CANCER.  549 

seeondcirily  affected  may  be  judged  of  by  the  following  facts  given 
by  Dr.  Ariiott'  of  tlie  Middlesex  Hospital: 

In  34  cases  there  was  observed  no  secondary  deposit. 

"  20  "  "  cancerous  affection  of  lymphatic  glands. 

"  5  "  "  '•             "            the  ovaries. 

"  3  "  "  "            "           the  liver. 

"  2  "  "  "            "           the  lungs. 

"  1  "  "  "             "            the  heart. 

'•  1  "  "  "            "           the  breasts. 

"  1  "  "  "             "            the  peritoneum. 

Scirrhous  cancer  presents  as  its  predominant  anatomical  charac- 
teristic the  large  amount  of  connective  tissue  and  the  small  amount 
of  cellular  elements  of  which  it  is  composed;  and  as  its  cliief  clinical 
feature,  its  gradual  development  and  comparative  slowness  of  growth 
and  progress.  The  abundant  stroma  alluded  to  soon  contracts,  and 
in  so  doing  checks  epithelial  generation,  causes  atrophy  of  almost 
all  but  peripheral  cells,  and  by  compressing  bloodvessels  limits 
vascular  supply.  These  growths  offer  to  the  examiner,  before 
ulceration  has  occurred,  a  hard,  nodular,  and  resisting  surface. 

Encephaloid  cancer  of  the  cervix  is  characterized  by  a  small  amount 
of  stroma  and  a  large  amount  of  cells.  Clinically  it  is  marked  by 
its  rapid  growth,  tendency  to  hemorrhage,  and  early  disintegra- 
tion. Upon  physical  examination  during  life  it  presents  a  soft, 
lobulated,  elastic  surface. 

Figs.  156  and  157,  after  Billroth,  showing  the  arrangement  of 
cellular  and  connective  tissue  elements,  will  prove  instructive. 

Epithelial  cancer  differs  greatly  both  in  anatomical  and  clinical 
features  from  the  forms  just  enumerated,  and  claims  especial  con- 
sideration. Commencing  by  excessive  generation  of  the  cells  which 
characterize  the  part  upon  which  the  morbid  influence  is  excited, 
it  develops  itself  always  in  connection  with  epithelial  covered 
surfaces — skin  or  mucous  membrane.  In  some  cases  the  stroma  is 
very  abundant;  in  others  it  is  almost  entirely  wanting.  As  the 
cells  increase  in  this  they  arrange  themselves  into  epithelial  brood 
nests  or  spaces. 

The  importance  of  the  distinction  between  this  form  of  cancer 
and  those  previously  mentioned  is  at  present  not  as  generally  ac- 
cepted as  it  was  twenty  years  ago.  At  that  time  pathologists 
thought  it  necessary  to  divide  cancers  into  two  separate  classes: 
those  which  were  essentially  true  cancer,  and  those  which  were  ('^5oJ) 
like  unto,  though  not  identical  with,  that  terrible  malady.      Tn 


'   Path,  'i'r.nis..  ISTO. 


550 


CANCEK    OF    THE    UTERUS. 
Fig.  156. 


Cancer  of  mamma;  stroma  and  cells.     (Billrotb.) 


Fig.  157. 


Connective  tissue  framework  of  cancer  of  mamma.     Brnslied-ont.  alcohol 
in-epanitiou.     (Billroth.) 

1846,  Lebert  gave  to  these  growths  the  name  of  "  cancroid"  for  the 
reason  just  given,  and  in  1852,  Hannover,  from  the  fact  that  this 


EPITHELIAL    CANCER. 


551 


variety  of  disease  was  known  to  consist  in  a  morbid  Lypergenesis 
of  normal  epithelium,  called  them  "epithelioma." 

For  a  long  time  the  current  of  opinion  appeared  to  set  in  favor 
of  making  a  wide  distinction  between  the  two  atiections ;  one 
being  looked  upon  as  a  disease  having  its  origin  in  a  peculiar  cc^n- 
(lition  of  the  system,  and  the  other  as  one  of  local  nature  only. 
More  recently  a  different  feeling  has  prevailed,  pathologists  strongly 
inclining  to  the  view  that  cancroid  growths  are  really  members  of 
the  family  of  cancers,  differing  from  them  histologically  chiefly  in 
the  features  which  I  have  mentioned.  On  their  part,  clinicists  no- 
ticed very  marked  differences,  chief  among  which  are  tardiness  of 
systemic  poisoning  in  cancroids,  and  slighter  tendency  to  return  of 
the  disease  after  amputation.  Rokitansky^  said  of  them:  "In 
many  cases,  however,  notwithstanding  precisely  the  same  morpho- 
logical and  chemical  relations,  they  accord  so  entirely  in  all  their 
manifestations  with  the  cancers,  that  we  classify  them  with  these 
as  a  further  variety  of  medullary  carcinoma,  to  which  in  their 


Fig.  158. 


/ 
Flat  epithelial  c-mcei  of  cheek 


Glandular  nigiowth  of  rete  M.ilpighii 


into  counective  tissue.     (Billroth.) 

lineaments  also  they  approximate  the  most  nearly.  This  occur- 
rence we  believe  to  be  limited  to  the  mucous  membranes  and  the 
common  integuments."  Virchow,  whose  investigations  have  been 
later  than  those  of  Hokitansky,  regards  epithelioma  as  well  as  cancer 
as  due  to  a  generation  of  normal  cells  excited  into  a  morbid  activity 
by  the  unknown  influence  which  constitutes  the  cause  of  cancerous 


Op.  cit.,  vol.  i,  p.  217, 


552  CANCER  OF  THE  UTERUS. 

affections.  He'  has  demonstrated  the  development  of  cancroid  sub- 
stance within  the  uterine  wall  as  well  as  upon  its  mucous  mem- 
brane. 

In  the  commencement  of  each  variety  of  malignant  disease  the 
clinical  differences  would  be  easily  recognized  ;  bat  as  epithelioma 
advances,  and  the  deeper  tissues  become  involved,  a  differentiation 
will  often  become  not  only  difficult  but  impossible. 

Epithelial  cancer  may  affect  the  uterus  in  two  entirely  different 
forms.  The  first  is  characterized  by  a  strong  tendency  to  ulcera- 
tion;  the  second  by  formation  of  a  tumor,  or  fungus-like  mass, 
which  at  a  later  period  is  attacked  by  ulceration.  These  forms 
have  been  designated  as — 

Ulcerating  epithelioma ; 
Vegetating  epithelioma. 

The  term  corroding  ulcer  was  applied  by  Dr.  John  Clarke,  of 
London,  and  subsequently  by  his  brother  Sir  Charles  Mansfield 
Clarke,  to  a  form  of  ulcer  of  the  cervix  in  which  nothing  l)ut  rapid 
destruction  of  tissue  is  noticed  as  a  pathological  lesion ;  in  which 
there  is  no  hardness  of  the  part  affected,  no  induration  nor  inflam- 
mation of  surrounding  organs  ;  nothing  but  molecular  death  in  the 
cervix  uteri,  and  disappearance  of  its  structure  as  if  by  liquefaction. 
It  has  been  described  under  the  names  of  rodent  ulcer,  diffuse 
ulcerative  cancer,  epithelial  cancer,  and  cancroid  of  the  uterus. 

All  authorities  agree  that  this  affection  is  comparatively  rare. 
Dr.  AshwelP  remarks:  "  For  one  case  of  corroding  ulcer  we  meet 
with  ninety  or  a  hundred  of  canc-er  of  the  uterus ;"  and  he  further 
states  that  in  the  appropriate  ward  at  Guy's  Hospital  at  the  time 
of  his  writing,  not  one  example  of  this  malady  had  appeared.  In 
five  hundred  recorded  cases  of  uterine  disease  in  that  hospital  not 
one  case  of  corroding  ulcer  was  to  be  found.  This  is  the  experience 
of  all  authors  who  make  their  reports,  not  from  clinical,  but  from 
careful  post-mortem  evidence.  Those  who  rely  upon  clinical  obser- 
vations alone  report  the  disease  much  more  frequently;  but  it  is 
highly  probable  that,  as  Scanzoni^  remarks,  an  error  has  been  made 
in  snch  cases  with  reference  to  its  anatomical  characteristics.  It 
should  be  borne  in  mind  that  many  cases,  proved  by  the  microscope 
in  post-mortem  inspection  to  be  unquestionable  carcinoma,  have 
run  a  course  very  similar  to  that  of  this  affection.  Ashwell  states 
that  on  several  occasions  where  a  diagnosis  of  corroding  ulcer  had 


Klob,  op.  cit.,  p.  19.  ^  Dis.  of  Women,  p.  318. 

Op.  cit..  p.  217. 


EPITHELIAL    CANCER. 


553 


been  made,  post-mortem  examination  gave  evidence  of  other  forms 
of  cancer;  and  Scanzoni  tells  of  a  case,  occurring  in  the  clinique  at 
Prague,  in  which  at  an  autopsy  all  present  were  inclined  to  reverse 
their  diagnosis  of  carcinoma  and  adopt  that  of  corroding  ulcer, 
until  the  matter  was  settled  by  necropsy. 

Pathologists  are  now  very  generally  agreed  that  this  aifection  is 
a  variety  of  epithelial  cancer,  as  the  following  table  will  i)rove.  In 
preparing  it  no  author  is  quoted  who  wrote  over  twenty-five  years 
asro. 


A  ulh  ority. 
Dr.  West 

Dr.  Graily  Hewitt  . 

Dr.  Churchill  . 

M.  Aran . 

Dr.  Scanzoni  . 

M.  Nonat 

M.  Becquerel  . 

Dr.  Ashwell    . 

Dr.  H.  Bennet 

Mr.  De  Morgan 

Mr.  Arnott      .     ■    . 

Dr.  Byford 

Dr.  Lever 

Dr.  Kiwisch    . 

M.  Columbat  de 

L'Isere 
-M.  Courty 


Opinion  as  to  Pathology. 
Epithelial  cancer 

A  form  of  cancer 

"  Essentially  different"  from 
cancer      .         .         .         . 
DiflFuse  ulcerating  cancer 

Decomposed  medullary  can- 
cer  .         .         .         .         . 
Epithelial  cancer 

Epithelial  cancer 

Similar  to  lupus  . 

Epithelial  cancer 

"A  modification  of  epithe- 
lioma"     .         .         .         . 
"  A  form  of  epithelioma"     . 

Epithelial  cancer 

Malignant  ulcer  . 

Decomposed  medullary  can- 
cer    

Compares  it  to  noli  me  tan- 
gere  .... 

I'^ipithelial  cancer 


Where  reported. 

West  on  Diseases  of  Females, 
p.  270. 

Hewitt  on  Diseases  of  Women, 
Amer.  ed.,  p.  211. 

Churchill  on  Diseases  of  Wo- 
men, p.  208. 

Aran,  Mai.  de  I'Uterus,  p.  937. 

Scanzoni    on    Diseases    of    Fe- 
males, p.  227. 
Nonat,  Mai.  de  I'Uterus,  p.  521. 

Becquerel,    Mai.    de    I'Uterus, 

tom.  ii,  p.  209. 
Ashwell  on  Diseases  of  Females, 

p.  319. 
Bennet  on  Uterus,  p.  386. 

Essay  before  London  Path.  Soc, 

March,  1874. 
Discussion  before  London  Path. 

Soc,  March,  1874. 
Byford,  Med.  and  Surg.  Treat. 

of  Women. 
Lever  on  the  Diseases  of  the 

Uterus,  p.  149. 
Scanzoni,    Dis.  of  Females,   p. 

227. 
On  Females. 

Mai.  de  I'Uterus,  p  87.5. 


Rokitansky'  alludes  to  the  disease  thus:  "  We  also  find  primary 
and  syphilitic  ulcers,  cancerous  ulcers  that  have  resulted  from  the 
fusion  of  cancerous  morbid  growths,  the  so-called  phagedenic  ulcer 
of  the  08  tincse,  Clarke's  corroding  ulcer.     The  latter  may  be  com- 


'  Path.  Anat.,  Sydenham  ed.,  vol.  ii,  p.  220. 


554  CANCEE  OF  THE  UTERUS. 

pared  to  the  phagedenic,  cancerous  sore  of  the  skin;  without  having 
a  morbid  growth  for  its  base  it  gradually  destroys  the  cervix  and 
even  the  greater  part  of  the  uterus,  and  may  extend  to  the  rectum 
and  bladder." 

"In  some  dissections  that  I  had  made,"  says  Mr.  Arnott,^  "it 
seemed  to  me  that  rodent  ulcer  was  a  form  of  epithelioma,  for  one 
sees  deep  down  an  appearance  like  the  cells  of  the  rete  mueosum, 
and  occasionally  the  bird's-nest  body;  the  cells  are  more  closely 
coherent  than  in  epithelioma,  because  they  resemble  more  the  cells 
of  the  rete  mueosum,  not  the  epidermis  cells ;  therefore  they  have 
a  still  lower  mixlignancy  than  any  ordinar}''  epithelioma." 

The  tendencj-  of  the  newly  formed  cells  is  to  rapid  death.  As 
the  process  of  destruction  advances  through  the  mucous  membrane 
into  the  parenchyma  beneath  it,  and  profuse  hemorrhages  occur, 
the  patient  is  gradually  exhausted ;  and  as  the  peritoneum  in  time 
becomes  invaded,  peritonitis  of  fatal  type  is  excited.  Unlike  other 
cancers,  however,  its  course  is  often  slow,  and  years  may  pass  be- 
fore death  results.  All  varieties  of  cancer  ultimately  ulcerate. 
The  prefix,  "ulcerating,"  as  here  employed,  api)lies  only  to  that 
variety  whose  primary  feature  is  to  break  down  in  this  way. 

That  form  of  e[)ithelioma  called  "  vegetating,"  and  which  has 
been  at  difterent  times  described  under  a  variety  of  names,  has  the 
following  characteristic  features:  it  consists  in  the  growth  of  a 
lowly  organized  tumor,  which  creates  hemorrhage,  fetid  discharge, 
and  hydrorrhoea.  There  is  an  extraordinary  develo^nncnt  of  cer- 
vical villi,  an  increase  of  their  vessels,  and  a  great  activity  in  the 
growth  of  the  cells  which  cover  them;  a  "proliferation,"  as  it 
is  termed  by  Virchow.  A  morbid  influence,  the  nature  of  which 
is  unknown  to  us,  stimulates  the  activity  of  cell  growth,  so  that 
cells  thickly  cover  the  villi.  "These  growths,"  says  Prof.  J.  H. 
Bennet,  "speaking  generally,  are  almost  wholly  composed  of 
epithelial  scales."  In  addition,  the  villi  increase  in  size  and  length, 
their  bloodvessels  enlarge,  and  a  true  papilloma  or  papillary  tumor 
is  inaugurated.  "  The  gall-nut  which  arises  in  consequence  of  the 
puncture  of  an  insect,  the  tuberous  swellings  wdiich  mark  the  spots 
on  a  tree  when  a  bough  has  been  cut  off,  and  the  wall-like  elevation 
which  forms  around  the  border  of  tlie  wounded  surface,  produced 
by  cutting  down  a  tree,  and  Avhich  ultimately  covers  in  the  surface, 
all  of  them  depend  upon  a  proliferation  of  cells  just  as  abundant, 
and  often  just  as  rapid  as  that  which  we  perceive  in  a  tumor  of  a 


'  Discussion  before  London  Path.  See. 


EPITHELIAL    CANCER. 


555 


proliferating  part  of  the  human  body."^     Fig.  159  represents  one 
of  these  growths  in  section. 

Fig.  159. 


Transverse  section  of  a  vegetating  epitbelioma.     (Vircliow.) 

It  must  not  he  supposed  that  these  masses  are  supplied  with 
blood  only  by  the  vessels  of  the  villi.  These  ramify  outside  of 
their  proper  canals,  and,  running  into  the  masses  of  cells,  allow  of 
transudation  of  serum,  which  constitutes  the  watery  discharge  so 
characteristic  of  the  disease,  and,  being  ruptured,  give  forth  a  j)ro- 
fuse  flow  of  blood. 

These  tumors,  commencing  as  papillary  hypertrophies  on  the 
cervix  or  os,  are  at  first  local,  but  in  time  afltect  the  constitution. 
They  are  sometimes  engrafted  upon  true  cancerous  deposit  in  the 
cervical  parenchyma. 

Their  most  frequent  site  is  the  vaginal  portion  of  tlie  cervix, 
1  lit  from  this  point  the  morbid  process  may  spread  into  the 
i: ferine  cavity  or  down  into  the  vagina.  An  important,  indeed  a 
vital  question  as  to  such  growths  is  this:  is  every  cauliflower 
■xcrescence  a  malignant  disease?  Virchow,  than  whom  we  know 
»f  no  better  authority,  is  decidedly  of  opinion  that  it  is  not. 
I  '  The  pathological  importance  of  a  papillary  tumor,"  says  he,  "  is, 
'  (t  least  as  far  as  I  know,  determined  by  the  condition  of  its  basis- 


'   Yircliow,  Celluhxr  Pathology, 


556  CANCER    OF    THE    UTERUS. 

substance,  or  by  that  of  the  parenchyma  of  the  villi  themselves ; 
and  a  formation  can  only  be  pronounced  to  be  cancroid  or  car- 
cinoma when,  in  addition  to  the  growth  of  the  surface,  the  pecu- 
liar degenerations  which  characterize  these  two  kinds  of  tumors 
take  place  also  in  the  deeper  layers  or  in  the  villi  themselves." 
Virchow  then  believes  that  some  tumors,  resembling  in  every 
outward  aspect  vegetating  epithelioma,  are  really  non-malignant 
papillomata.  The  difterence  between  these  and  the  real  epithe- 
lioma is  to  be  found  by  microscopic  examination  of  the  submu- 
cous tissue.  In  the  one  case  it  is  healthy,  in  the  other  diseased. 
"  Whilst,"  says  Klob,  "  in  the  benign  form,  simply  an  arborescent 
framework  is  covered  by  a  more  or  less  thick  layer  of  basement- 
epithelium,  in  the  cancroid  tumor,  so-called  cancroid  alveoli  are 
developed  in  the  substance  proper  of  tiiC  tumor,  and  also  in  the 
'parent  tissue,'  which  is  atioctcd  with  hyperi)lasia  of  connective 
tissue."  It  is  a  note-worthy  and  interesting  fact  that  this  opinion, 
arrived  at  by  these  learned  Gorman  pathologists  by  careful  micro- 
scopic research,  was  maintained  as  a  result  of  clinical  observation 
many  years  ago  by  Gooch,  who  said  :  "  I  do  not  believe  that  any 
man  can  tell  infallibly  by  touch  whether  a  tumor  in  the  vagina  is 
a  malignant  excrescence,  which  is  to  grow  again,  or  a  benign  one, 
which,  if  removed,  will  never  return." 

The  pathological  condition  that  we  have  thus  far  described  may 
be  styled  the  first  stage  of  the  disease.  In  time  ulceration  occurs 
in  the  mass  thus  created,  which,  rapidly  breaking  down  its  tissue, 
opens  large  and  numerous  vessels,  and  destroys  life  by  long-con- 
tinued and  profuse  hemorrhages. 

Klob'  describes  two  forms  of  malignant  papilloma;  one  which 
goes  on  to  the  creation  of  a  tumor  of  some  size  and  then  breaks 
down ;  the  other,  which  consists  merely  of  small  nodules  upon  the  > 
cervix,  which  rapidly  ulcerate  and  eat  away  this  part,  and  in  time  > 
the  body  of  the  uterus.     These  tumors  may  grow  from  the  vaginal 
portion  of  the  cervix,  from  the  cervical  canal,  or  from  the  mucous  - 
membrane  of  the  body  of  the  uterus. 

The  authority  of  A^irchow  has  been  already  quoted  to  prove  how 
difficult  is  a  differentiation  of  malignant  from  benign  papilloma. 
Indeed,  Scanzoni  declares  that  Virchow  is  of  opinion  that  "  the 
excrescence  is  at  first  a  simple  papillary  tumor,  which  afterwards 
passes  into  a  cancroid  state."    At  the  same  time  that  differentiation 

•  Op.  cit..  p.  189. 


I 


PREDISPOSING    CAUSES.  557 

is  difficult  in  such  a  case,  its  great  importance,  as  affecting  the 
validity  of  deductions  as  to  the  results  of  treatment,  must  be  evident. 
The  following  quotation  from  Graily  Hewitt's^  excellent  work  will 
illustrate  this  remark.     In  speaking  of  the  fatality  and  duration 

Fig.  160. 


Vegetating  epithelioma.     (Siiapson.) 

of  cancerous  and  cancroid  affections,  he  says,  "  One  of  the  most 
valuable  facts  in  this  connection  is  given  by  Sir  J.  Y.  Simpson  in 
his  'Lectures  on  Diseases  of  Women.'  The  patient,  the  subject  of 
the  case,  had  a  large  cauliflower  excrescence,  the  size  of  an  egg, 
removed  eighteen  years  previously.  Since  that  period  she  has  had 
five  children,  and  was  still  alive.  With  reference  to  this  case  it 
should  be  stated  that  no  'caudate  or  spindle-shaped  bodies'  were 
found  in  the  tumor  removed."  Now  if  we  are  to  accept  the  reve- 
lations upon  this  subject  made  by  recent  investigators,  of  what  real 
value  is  such  a  case?  It  is  more  likely  to  mislead  than  to  guide  the 
practitioner  correctly.  Klob,^  while  guarding  against  the  fallacy  of 
judging  by  external  appearances,  gives  this  method  of  differentia- 
tion by  the  microscope.  "  In  simple  papilloma  there  is  a  frame- 
work covered  merely  by  a  thick  layer  of  basement-epithelium ;  in 
malignant  papilloma  there  are  alveoli  filled  with  cells  constituting 
the  so-called  'brood-cavities.'" 

Predisposing  Causes. — Those  predisposing  causes  which  are  gene- 
rally admitted  may  be  tjius  enumerated  : 

Hereditary  tendency; 

Middle  or  advanced  life; 

Race,  the  African  enjoying  partial  immunity; 

Repeated  parturition ; 

General  depreciation  of  vital  forces. 

'  Op.  cit.,  p.  578.  "  Op.  cit,  p.  187. 


558  CANCER    OF    THE    UTERUS. 

Hereditary  teiidencj',  once  generally  admitted  as  a  fruitful  pre- 
disposing cause,  is  now  questioned  by  many. 

Lebert  found  evidences  of  hereditary  tendency  in  14  out  of  102  cases. 
Paget  "  "  "  "  T8      "       322     " 

Sibley  "  "  "  "  33      "       305     " 

More  rec;ently  Sir  James  Paget  declares  that  in  his  experience, 
about  one  case  in  three  has  been  hereditary. 

Although"  cases  have  been  reported  at  the  extremes  of  woman- 
hood, it  is  generally  admitted  that  few  occur  before  twenty  and 
after  sixty.  The  most  fruitful  period  is  from  40  to  50 ;  the  next 
from  30  to  40;  the  next  from  20  to  30;  and  the  next  from  50  to  60. 

Scanzoni  gives  the  ages  of  108  cases  treated  by  him. 


4  were  between  20  and  25. 
4    "  "        25  and  30. 

17  "    *'    30  and  35. 

18  "    "    35  and  40. 


45  were  between  40  and  45. 
15  "     "    45  and  50. 

4  "     "    50  and  55. 

1  was    "    55  and  60. 


The  youngest  was  23  and  the  oldest  59  years  of  age. 

The  ])lack  races  appear  to  enjoy  to  a  limited  extent  immunity 
from  this  disease  when  compared  with  the  white. 

Prof.  Barker  in  an  interesting  essay  upon  this  subject,  published 
in  the  Transactions  of  the  New  York  Academy  of  Medicine  for 
1870,  cites  the  following  statistics  by  Prof.  Ohisolm  of  Baltimore : 

Registrar's  report  in  South  Carolina  for  1859 — 

In  2423  deaths  among  whites,  20  were  of  cancer ; 
"  7277      "  '•       blacks,  29      " 

Judging  from  these  statistics,  the  exemption  of  the  black  races 
is  by  no  means  so  complete  as  the  general  impressions  of  many 
practitioners  appear  to  argue. 

Cancer  of  the  uterus  is  more  frequently  observed  among  multi- 
parse  than  nulliparae.     Of  Scanzoni's  108  cases — 

6  had  been  delivered  11  times. 
3        "        •'       "       10      " 

2  "        «       "       11      " 

14         "         "       «'         8      "  - 

13        «        «       "         7      <> 

21        «        "       ♦'        6      "  ' 

10        "        "       "         5      " 

3  "        «       "         4      " 

The  results  of  Mr.  Sibley's  investigations  in  the  Middlesex 
Hospital  go  to  prove  this  fact.  He  found  that  the  average  number 
of  children  borne  by  women  suffering  from  this  disease  was  30  per 
cent,  in  advance  of  the  average  number  of  all  iparriages. 


SYMPTOMS.  659 

Although  it  is  maintained  by  some,  that  cancer  as  commonly 
affects  persons  in  perfect  health  as  it  does  the  weak,  it  is  generally 
admitted  that  depreciating  influences  exerted  upon  the  general  sys- 
tem have  a  predisposing  effect.  Among  these  may  be  especially 
mentioned  grief  and  mental  anxiety,  (observed  by  Scanzoni  84  times 
in  108  cases,)  overlactation,  the  existence  of  any  diathetic  state,  life 
in  a  large  city,  and  the  state  of  spantiemia  engendered  by  hard  labor, 
exposure,  insuflScient  food,  or  vicious  habits. 

Exciting  Causes. — The  exciting  causes  are  entirely  unknown. 
As  has  been  already  stated,  the  view  once  entertained  by  many, 
that  cancer  is  often  a  result  of  chronic  inflammation,  is  now  gene- 
rally repudiated.  In  my  own  experience  I  have  yet  to  find  a  case 
even  remotely  sustaining  such  a  position.  There  is,  however,  be- 
lieved to  exist,  to  use  the  words  of  Paget,  "a  local  and  a  con- 
stitutional origin  of  cancer."  Mr.  Hutchinson  humorously  styles 
cancer  "a  rebellion  of  cells."  It  is  the  cause  which  incites  this 
rebellion  which  has  thus  far  eluded  the  search  of  pathologists  and 
clinicists. 

Symptoms.— The  disease  may  pass  through  its  period  of  inception 
and  make  considerable  progress  towards  a  fatal  issue  without 
developing  any  symptoms  which  attract  the  attention  of  the  patient. 
Or  only  slight  leucorrhoea  and  hemorrhage  may  exist,  which  may 
liave  been  passed  over  as  trivial  circumstances,  not  deserving  treat- 
ment or  investigation.  Usually  the  following  symptoms  develop 
themselves  and  become  more  and  more  prominent  as  molecular 
death  advances: 

Pain  through  the  pelvis  ; 

Tenderness  up'on  movement  or  coition; 

Menorrhagia  and  metrorrhagia ; 

Ichoix)us  and  fetid  leucorrhcea ; 

Ilydi'orrhoea ; 

Dark,  grumous  discharge ; 

Constitutional  debility ; 

Pallor  and  cachectic  facies ; 

Vesico- vaginal  or  recto- vaginal  fistulfe. 

Pain  and  tenderness  are  not  nearly  so  constant  or  severe  as  is 
often  supposed,  and  they  may  both  be  entirely  absent. 

Menorrhagia  and  metrorrhagia  may  exist  even  before  ulceration 
has  occurred,  resulting  then  from  congestion  of  the  mucous  mem- 
brane. But  it  is  not  until  after  the  inauguration  of  the  process  of 
<k'struction  that  they  become  alarming  or  excessive. 


560  CANCER  OF  THE  UTERUS. 

Ichorous,  watery,  and  grumous  discharges  very  generally  mark 
the  advance  of  the  disease.  The  first  of  these  discharges  produces 
erythema,  erosions,  vaginitis,  and  sometimes'  a  strong  sexual  appe- 
tite. The  second  exhausts  the  patient  by  draughts  made  upon 
the  serum  of  the  blood.  The  third  creates  fetor,  and  sometimes 
results  in  septicaemia,  for  the  material  giving  color  and  odor  to  the 
flow  is  a  putrilage  formed  by  the  detritus  from  the  decaying 
uterus. 

Constitutional  debility  and  cachectic  facies  are  the  results,  in 
part,  of  the  malignant  toxremia  which  is  the  basis  of  the  disorder, 
in  part  of  exhaustion  produced  by  loss  of  blood  or  some  of  its 
elements.  Should  the  walls  of  the  rectum  and  bladder  become 
implicated,  as  they  very  often  do,  the  functions  of  these  viscera  are 
deranged,  and  the  feces  or  urine,  or  both,  pour  out  through  the 
vagina,  increasing  the  misery  of  the  patient. 

Physical  Signs. — Suspicion  is  generally  first  aroused  and  physical 
exploration  prompted  by  these  three  symptoms:  menorrhagia,  fetid 
discharge,  and  ichorous  leucorrhoea.  They  belong  to  the  second  or 
ulcerative  stage  of  the  affection,  and,  as  Dr.  Henry  Bennet  has  well 
established,  it  is  almost  invariably  in  this  stage  that  the  physician 
is  consulted.  Before  the  occurrence  of  this  stage  no  symptom 
usually  exists  which  calls  for  physical  exploration. 

I  have  seen  but  two  cases  which  I  am  positive  were  incijuent  or 
non-ulcerated  scirrhous  cancer.  In  these  the  diagnosis  was  made 
by  the  peculiarly  hard,  nodular  sensation  yielded  by  the  cervix,  and 
in  one  by  the  coincident  implication  of  the  vagina.  I  feel  sure, 
however,  that  he  who  ventures  Ujion  a  decision  as  to  the  nature  of 
the  disease  at  this  stage  must  expose  himself  to  great  risk  of  error. 
The  mere  fact  of  the  cervix  being  excessively  hard  and  nodular  is 
not  enough  to  warrant  a  diagnosis.  This  must  be  accompanied 
by  other  reliable  signs,  as  menorrhagia,  hydrorrhoea,  and  constitu- 
tional failure,  to  make  a  positive  conclusion  admissible. 

For  this  period  of  the  disease,  a  period  at  which  diagnosis  is 
of  extreme  importance,  in  view  of  the  fact  that  then  ablation 
oft'ers  the  greatest  hope  for  permanent  or  temporary  relief,  Spiegel- 
berg  offers  a  valuable  resource  in  the  use  of  sponge  tents.  If  the 
induration  of  the  tissue  be  benign,  the  dilating  influence  of  the 
tent  will  produce  a  degree  of  softening,  while,  if  it  be  due  to  ma- 
lignant disease,  the  tissue  will  remain  unyielding  and  hard. 

'  I  have  never  met  with  thia  symptom. 


DIFFERENTIATION.  561 

After  ulceration  has  occurred,  diagnosis,  to  an  experienced  ex- 
aminer^ is  as  simple  and  certain  as  it  is  obscure  and  uncertain 
before  it.  The  finger  discovers  an  absolute  destruction  of  tissue, 
and  finds  the  walls  of  the  deep  and  ragged  ulcer  producing  it, 
covered  over  with  a  crumbling,  brittle  mass,  interference  with 
which  causes  hemorrhage.  The  uterus  is  often  fixed  by  secondary 
inflammation,  or  diftuse  deposit  of  cancerous  matter,  and  the  walls 
of  the  vagina  near  the  uterine  junction  participate  in  the  deposit. 
Sometimes  there  is  a  stricture  of  the  rectum,  which  especially  en- 
gages the  attention  of  the  patient,  who  suspects  no  disease  of  the 
uterus  or  vagina. 

It  is  difficult  to  describe  to  another  the  peculiar  sensation  yielded 
by  an  ulcerating  cancer,  but  it  is  easy  to  appreciate  it  by  touch. 
He  who  carefully  explores  one  case  and  marks  the  hard,  unyielding 
border  and  brittle  surface,  with  its  marked  tendency  to  crumble 
and  produce  hemorrhage,  will  rarely  fail  to  recognize  another. 

Nevertheless,  it  is  in  all  cases  safe,  and  in  some  essential,  to  re-, 
move  a  small  portion  of  the  cancerous  material  if  it  can  be  done 
without  creating  great  flow  of  blood,  for  examination  with  the 
microscope.  And  now  arises  the  question,  what  are  the  micro- 
scopic tests  of  cancer?  This  subject  is  one  which  I  cannot  leave 
unnoticed,  and  yet  one  with  which  I  must  deal  as  cursorily  as  is 

I  consistent  with  a  concise  statement  of  the  existing  views  of  patho- 

I  legists  upon  it.     This  can,  I  think,  most  readily  be  done  by  a  series 
of  propositions. 

1st.  There  is  no  typical  cancer  cell,  which,  separated  from  its  sur- 

'  roundings  and  viewed  as  an  entity,  enables  a  microscopist  to  pro- 
nounce upon  a  growth. 

2d.  There  are  certain  combinations  of  cells,  alveoli,  and  stroma, 

^  which  do  enable  a  microscopist  to  jjronounce  an  opinion  as  to  the 
benignity  or  malignancy  of  a  growth. 

3d.  This  combination  consists,  in  general  terms,  in  the  existence 

'  of  a  fibrous  stroma,  containing  ovoid  alveolar  spaces,  filled  with 
masses  of  cells  with  large  single  or  multiple  nuclei,  and  all  bearing 

w  more  or  less  closely  a  resemblance  to  epithelium. 

Differentiation. — Upon  theoretical  grounds  it  might  be  supposed 
that  the  diagnosis  of  ulcerated  cancer  would  be  so  simple  that  few 
errors  would  occur  in  reference  to  it.  This  is  far  from  the  truth. 
A  skilful  diagnostician  would,  indeed,  generally  arrive  at  a  correct 
conclusion,  Ijut  I  know  of  no  disease  of  the  genital  organs  of  the 
female,  unless  it  be  pelvic  peritonitis,  which  so  frequently  gives 
36 


562  CANCER    OF    THE    UTERUS. 

rise  to  errors  of  diagnosis  with  the  inexperienced.     It  may  be  con- 
founded with — 

Eversion  of  cervix  from  laceration ; 

Papillary  hypertrophy  of  the  cervix  (cock's  comb  ulcer); 

Sloughing  fibrous  polypus ; 

Uterine  fibroids  ; 

Syphilitic  ulcer ; 

Areolar  hyperplasia  of  cervix  with  metrorrhagia ; 

Sarcoma  of  the  uterus. 

From  these  a  diflferentiation  should  be  arrived  at  by  careful  study 
of  the  progress  of  the  case,  by  the  degree  of  constitutional  implica- 
tion, by  the  results  of  microscopic  examination,  and  by  the  develop- 
ment of  a  tendency  to  return  after  removal,  A  positive  conclusion 
is  not  always  easy,  or,  without  delay,  even  jtracticable.  An  intel- 
ligent decision  of  the  question  must  depend  upon  care  in  investiga- 
tion, thoroughness  of  examination,  and  upon  time,  which  in  most 
cases  will  clear  up  all  doubt.  It  should  be  remembered  that  the 
diagnostician,  however  skilful  he  may  be,  who  bases  an  opinion  upon 
the  sensation  of  hardness  and  resistance  in  the  cervix,  is  running  a 
great  risk  of  error.  Let  it  be  borne  in  mind,  too,  that  s^^philitic 
ulcers  have  been  known  to  eat  into  the  bladder  and  rectum  and  create 
very  much  such  a  state  of  things  in  the  vagina  as  carcinoma  develops. 

Prognosis. — The  prognosis  is  pre-eminently  unfavorable.  Not 
only  is  it  so  from  the  fact  that  the  disorder  is  cancerous,  but  be- 
cause that  form  which  often  affects  the  uterus  belongs  to  the  most 
rapid  and  dangerous  of  its  varieties.  "  Medullary  carcinoma," 
says  Rokitansky,  "  is,  both  in  its  development  and  in  its  subse- 
quent course,  the  most  acute  of  all  cancers." 

In  some  cases  death  will  ensue  in  from  three  to  six  months, 
while  in  others  it  may  not  occur  for  five,  six,  or  seven  years.  The 
prognosis  should  be  governed  in  great  degree  by  the  character  of 
the  initial  affection :  true  carcinoma,  which  begins  with  profound 
implication  of  subjacent  parenchyma,  runs  a  more  rapid  course 
than  epithelioma,  which  often  involves  only  superficial  portions 
of  it.  The  general  experience  as  to  the  duration  of  cancer  of  the 
uterus  may  be  inferred  from  the  following  citation  of  authorities : 

Simpson  gives  as  an  average,  .         .         .         .  2  to  2^  years. 

Lebert  "  "  ....  about  16  months. 

West  "  "  ....  about  1.0  months. 

Barker  "  "  ....  .3  years  and  8  months. 

The  termination  of  cancer  of  the  uterus,  if  the  disease  be  unin- 
terfered  with,  is  very  generally  a  fatal  one,  although  it  is  admitted 


COMPLICATIONS.  563 

that  there  is  a, possibility  that  tlie  mass  may  slough  away,  the  surface 
heal  over,  and  the  patient  recover.  Scanzoni,  Rokitansky,  Kiwisch, 
Virchow,  and  Ivlob,  all  announce  this  fact,  strange  though  it  may 
appear  to  one  who  has  always  taken  a  more  gloomy  view.  "The 
cases  of  spontaneous  recovery  from  uterine  cancer,"  says  Roki- 
tansky,^ "are  of  extreme  rarity,  hut  they  do  occur."  "In  opposition 
to  the  above  phenomena,  which  inevitably  lead  to  death,"  says 
Klob,^  "the  universally  acknowledged  possibility  of  spontaneous 
recovery  from  uterine  cancer  is  interesting."  Let  it  be  remembered 
that  these  authors  distinguish  between  cancer  and  cancroid,  and 
are  Piere  writing  of  the  former. 

Under  these  circumstances  the  whole  vaginal  portion  of  the 
cervix  usually  sloughs  off,  and  the  os  internum  becomes  the  os 
externum.  Instances  of  spontaneous  recovery  from  true  carcinoma 
are  so  rare  and  interesting  that  I  refer  the  reader  to  the  history  of 
a  case  recorded  by  Prof.  Habit,  of  Vienna,  which  will  be  found 
in  the  Syd.  Soc.  Year-Book  for  1864,  at  page  401. 

When  death,  which  is  the  almost  inevitable  issue  of  cancer,  does 
occur,  it  is  usually  due  to  hemorrhage,  irritative  fever  which  as- 
sumes a  typhoid  form,  septicemia,  anaemia,  or  some  one  or  more 
of  the  numerous  complications  which  I  now  come  to  enumerate. 

Complications. — The  following  are  the  complications  which  most 
frequently  accompany  the  disease: 

Septicaemia  from  absorption  of  putrid  fluid; 

Cellulitis; 

Hydronephrosis ; 

Peritonitis: 

Tetanus ; 

Phlebitis ; 

Embolism ; 

Cancer  in  lymphatic  glands  or  other  organs. 

In  rare  cases,  as  has  been  pointed  out  by  Beatty,  Cruveilhier, 
and  others,  cancerous  degeneration  obstructs  the  ureters,  and  pro- 
duces in  this  way  urtemic  poisoning.  Dr.  Theophilus  Parvin 
records  an  instance  of  this  character  in  which  for  a  week  no  urine 
found  its  way  into  the  bladder,  and  the  symj^toms  of  urremia  were 
well  marked. 

Part  of  Uterus  Affected. — Cancer  much  more  frequently  affects 
the  neck  than  the  body  of  the  uterus,  although  some  authors,  with 

'  Op.  cit.,  vol.  ii.  p.  228.  ^  Qp.  cit.,  p.  203. 


564  CANCER  OF  THE  UTERUS. 

wliom  I  decidedly  agree,  look  uiion  cancer  of  the  body  as  much 
more  common  than  is  generally  thought. 

Although  cancer  developed  in  the  body  of  the  uterus  has  attracted 
very  little  attention,  it  is  by  no  means  exceedingly  rare.  Dr.  West 
has  met  with  it  in  two  out  of  one  hundred  and  twenty  cases  of 
malignant  uterine  disease,  and  Sir  James  Simpson  looks  upon  its 
frequency  as  represented  by  two  out  of  every  thirty  cases. 

The  most  marked  feature  of  the  aifection  thus  making  its  appear- 
ance is  the  obscurity  which  attends  diagnosis.  For  a  long  time, 
and  perhaps  tliroughout  the  case,  uterine  hemorrhage  and  fetid 
discharges  will  be  the  symptoms  which  will  excite  suspicion. 
These  leading  to  further  and  fuller  exploration,  a  portion  of  the 
morbid  tissue  will  be  removed  by  the  curette,  examined  by  the 
microscope,  and  thus  the  diagnosis  will  be  established. 

Scirrhus,  which  is  so  rare  as  to  be  denied  l)y  some  even  in  the 
neck,  never  affects  the  body,  and  so  rarel}-  does  encephaloid  do  so 
that  some  pathologists  declare  that  no  unquestionable  case  is  on 
record.  The  supposed  cases  are,  according  to  them,  really  instances 
of  sarcoma,  tuberculosis,  or  sloughing  fibroid  growths.  When 
malignant  disease  does  originate  in  the  cavity,  it  assumes  the  form 
of  epithelioma. 

Peculiar  Features  of  Cancer  of  the  Body. — The  symptoms  which 
mark  the  condition  are  : 

Hemorrhage,  especially  if  occurring  after  the  menopause; 

Depreciation  of  vital  forces  ; 

Cachectic  appearance ; 

Fetid  discharge ; 

Pains  of  severe  and  lancinating  character. 

These  symptoms  having  led  to  examination  of  the  uterus,  the 
following  physical  signs  will  probably  be  recognized: 

Enlargement  and  hardening  of  uterine  body  noticed  by  bi- 
manual palpation; 

Increased  capacity  of  uterus  ascertained  by  the  probe; 

Profuse  hemorrhage  upon  probing  ; 

Uterine*  tenesmus  with  dilatation  of  os ; 

Recognition  of  peculiar  intra-uterine  growth  by  introduction 
of  finger ; 

Microscopic  evidence  of  cancer. 

'  County,  op.  cit.,  p.  580. 


DIFFERENTIATION.  565 

Differentiation  of  Cancer  of  the  Body. — "When  the  rational  and 
physical  signs  here  enumerated  are  carefully  developed  and  con- 
sidered, a  very  probable  diagnosis  may  be  arrived  at.  Errors  of 
diagnosis  are  common  in  reference  to  this  disease  at  the  hands  of 
practitioners  who  are  not  familiar  with  the  subject,  or  who  rely 
too  firmly  upon  one  or  two  of  these  signs  or  symptoms.  I  have 
seen  each  one  of  the  following  conditions  mistaken  for  cancer  of 
the  body,  and  some  of  them  I  have  known  to  have  repeatedly  caused 
erroneous  diagnosis : 

A  sloughing  fibroid ; 
A  placenta  three  months  retained ; 
A  sponge  left  b}'  accident  in  utero; 
Syphilitic  disease  of  pelvic  bones ; 
Periuterine  cellulitis  or  peritonitis  ; 
Cystic  degeneration  of  chorion  (hydatids); 
Fibroid  tumors  or  polypi ; 
Entero-vaginal  fistula ; 
Intra-uterine  vegetations. 

I  do  not  deem  it  necessary  to  go  into  detail  upon  the  means 
necessary  for  accomplishing  the  difierentiation  of  these  affections 
from  malignant  disease.  It  will  suffice  to  say  that  in  cases  in 
which  doubt  exists  after  careful  investigation  by  all  the  other 
means  here  recommended,  removal  of  a  small  portion  of  the  mass 
and  its  examination  by  the  microscope  will  prove  of  the  greatest 
assistance,  and  will  probably  decide  the  question.* 

The  removal  of  a  portion  of  intra-uterine  cancerous  growth  may 
be  accomplished  in  three  ways.  The  simplest,  and  consequently 
the  best,  is  to  introduce  a  silver  catheter,  turn  it  around  once  or 
twice,  and  then  withdraw  it.  Upon  blowing  through  the  manual 
extremity  a  piece  of  the  growth  large  enough  for  examination  will 
j  generally  be  obtained,  for  these  masses  are  usually  \qtj  friable. 
Should  none  of  the  growth  be  obtained  in  this  way,  a  curette  may 
be  passed  gently  into  the  uterus,  and  greater  force  applied  for  the 
detachment  of  a  portion.  Should  even  this  fail  the  os  should  be 
dilated  by  tents,  and  the  desired  specimen  obtained  either  by  the 
finger,  a  wire  loop  curette,  or  a  pair  of  long-handled  scissors. 


'  It  may  be  of  service  to  practitioners  at  a  distance  from  cities  in  which  compe- 
tent microscopists  reside,  to  state  that,  in  sending  specimens  for  examination,  the 
best  preservative  menstruum  consists  of  glycerine  diluted  with  water.  Alcohol, 
carbolic  acid,  and  similar  fluids  contract  and  harden  the  structure  to  such  an  extent 
as  to  render  them  unfit  fur  examiiuition. 


566  CANCER  OF  THE  UTERUS. 

Treatment. — The  indications  for  treatment  are  these : 

To  amputate  or  destroy  the  diseased  part  as  completely  as  possible ; 

To  check  hemorrhage; 

To  relieve  pain ; 

To  secure  perfect  cleanliness  and  correction  of  fetor; 

To  sustain  the  general  strength. 

Review  the  complications  of  uterine  cancer,  and  it  will  be  seen 
that  many  of  them  are  of  a  most  fatal  character,  and  at  the  same 
time  entirely  beyond  the  resources  of  art.  A  certain  number, 
however,  which  would  prove  fatal  if  not  avoided  or  cliccked,  arc 
temporarily  under  the  control  of  the  physician.  Examples  of  these 
are  septicaemia,  hemorrliage,  exhaustion  from  pain,  ichorous  leu- 
corrhoea,  hydrorrhoea,  excessive  constitutional  debili*^y  from  the 
depraved  blood-state,  and  last,  though  not  least,  the  extreme  men- 
tal depression  which  is  the  consequence  of  bereaving  the  unfortunate 
sufferer  of  all  hope. 

No  single  plan  fulfils  so  many  of  the  indications  for  alleviating 
these  as  removal  or  destruction  of  the  growth,  but  no  practice  in 
reference  to  this  disease  can  be  so  pernicious  as  that  based  upon  the 
idea  that  because  there  is  cancer  of  the  uterus  some  surgical  pro- 
cedure must  be  resorted  to.  The  same  reasoning  which  applies  to 
malignant  diseases  in  other  parts  of  the  body  should  do  so  here. 
If  the  operator  be  convinced  that  decided  benefit  is  to  come  to  the 
patient  from  surgical  interference,  it  should  be  practised,  not  other- 
wise. Should  the  disease  be  detected  early,  and  sufficient  grounds 
be  discovered  for  a  positive  diagnosis,  the  propriety  of  complete 
removal  of  the  cervix  by  amputation  cannot  be  questioned.  If  the 
disease  be  scirrhous  or  encephaloid  cancer,  and  not  epithelioma,  the 
operative  procedure  will  generally  fail  in  efii*ecting  a  cure,  but  will 
probably  not  hasten  a  fatal  issue.  If  it  be  the  latter,  a  cure  may 
be  accomplished. 

In  the  great  majority  of  cases,  patients  suffering  from  uterine 
cancer  are  seen  so  late  that  surgical  interference,  established  Avith 
a  view  to  cure,  necessarily  fails  to  eftect  it ;  although,  practised  for 
relief  of  certain  symptoms,  and  thus  for  a  prolongation  of  life,  it 
is  frequently  of  a  great  deal  of  benefit.  Should  amputation  of  the 
neck  promise  entire  removal  of  the  morbid  tissue,  it  should  at  once 
be  accomplished,  for  by  it  absolute  cure  may  be  effected.  Incom- 
parably the  best  and  safest  means  of  doing  this  is  the  galvano- 
cautery,  and  unless  very  urgent  reasons  dictate  a  resort  to  the 
^craseur  or  scissors,  it  should  always  be  resorted  to.     In  our  time 


TREATMENT.  567 

it  is  usually  practicable  to  send  patients  to  large  cities  where  this 
instrument  can  be  placed  at  the  disposal  even  of  the  most  indigent. 
He,  who  in  place  of  doing  so,  performs  the  operation  by  other 
methods,  should  reflect  that  he  is  unquestionably  lessening  his 
patient's  chances  for  life.  I  have  performed  over  twenty  amputa- 
tions for  malignant  disease  by  galvano-cautery  without  one  fatal 
issue,  and  Dr.  John  Byrne,'  who  has  employed  this  method  more 
frequently  than  myself  or  any  other  operator  with  whose  practice 
I  am  familiar,  recommends  it  in  the  most  enthusiastic  terms.  He 
says  of  it :  "  It  would  appear  that  not  only  are  the  bloodvessels 
securely  sealed  up,  but  the  lymphatics  as  well,  and  hence  the  im- 
munity from  hsematoxic  and  inflamatory  complications."  Whether 
this  explanation  of  the  innocuousness  of  the  galvano-cautery  is 
correct,  I  am  not  prepared  to  say,  but  certainly  I  can  sul^stantiate 
Dr.  Byrne's  reports  of  the  absence  of  the  secondary  results  after  its 
use,  which  often  succeed  other  methods.  After  the  removal  of  the 
cervix  by  this  means,  it  is  surprising  to  see  how  little  constitu- 
tional excitement  shows  itself. 

To  be  efi:ectual,  amputation  should  be  rendered  complete,  either 
by  making  firm  traction,  and  stretching  the  resilient  tissues  of  the 
neck  before  application  of  the  wire,  so  that  the  remaining  stump 
will  be  represented  by  a  cone,  with  apex  towards  the  fundus ;  or, 
by  first  removing  the  neck  by  the  wire,  then  seizing  the  stump, 
and  by  the  cautery-knife  cutting  out  as  much  as  practicable  from 
the  tissue  of  the  uterus.  This  operation  will,  however,  be  fully 
described  under  the  head  of  Amputation  of  the  Cervix ;  and  it 
would  be  a  repetition  to  allude,  to  it  more  fully  here. 

Although  cancer  of  the  uterus  is  in  itself  no  more  malignant  in 
type  than  that  of  other  parts,  the  mamma,  for  instance,  it  is  much 
more  diflicult  of  entire  removal  for  the  reason  that  its  existence  is 
generally  ascertained  later  in  the  progress  of  the  case,  and  thus  it 
has  involved  deeper  layers  of  parenchyma  and  has  encroached  more 
upon  neighboring  organs.  It  may  not,  however,  be  uninteresting 
to  quote  here  a  table  by  Mr.  Birkett^  showing  the  results  in  the 
luration  of  life  of  removal  of  the  breast  in  150  women  affected  by 
cancer  of  that  organ. 

Of  the  150  patients  who  had  it  removed,  there  survived — 


'  Clinical  Notes  on  Electric  Cautery  in  Uterine  Surgery.     New  York,  Wm.  "Wood 
&  Co.,  1873. 
^  Graily  Hewitt,  op.  cit. 


568 


CANCER    OF    THE    UTERUS. 


8 

Above  10  years, 

.  2 

24 

"   11  " 

.  1 

38 

"   12  " 

.  1 

17 

"   13  " 

.  1 

21 

"   14  '' 

.  2 

7 

"   15  " 

.  1 

5 

About  23  " 

.  1 

10 

"   29  " 

.  1 

4 

"   32  " 

.  1 

4 

Under  1  year, 
Over    1    " 

2  " 

3  " 

5  " 

6  " 


"       9    "  .         . 

But  lot  US  suppose  that,  as  is  so  often  the  case,  the  whole  of  the 
diseased  part  cannot  be  removed  by  amputation  ;  is  it  better,  then, 
to  let  the  malady  progress  uninterfered  with,  except  by  means  to 
secure  cleanliness,  or  to  destroy  as  much  of  it  as  practicable,  in  the 
hope  of  thus  prolons^ing  life  ?  This  question  is  a  very  important 
one,  for  I  feel  sure  that  I  often  see  "meddlesome  surgery"  uselessly 
and  mischievously  applied  to  such  cases.  On  the  other  hand,  there 
can  be  no  question  of  the  fact  that  many  of  the  exhausting  symp- 
toms which  steadily  lead  to  death  can,  in  many  cases,  be  tempora- 
rily relieved  by  removal  or  destruction  of  the  superficies  of  the 
cancerous  mass.  The  best  reply  which  I  can  suggest  to  the  ques- 
tion just  asked  is  this : — If  the  disease  have  advanced  very  ftir,  and 
have  aft'ected  the  vagina,  deep  pelvic  tissues,  rectum,  or  bladder, 
and  the  patient's  condition  be  as  wretched  as  it  usually  is  under 
these  circumstances,  operative  procedures  of  all  kinds  should  be 
avoided: — If  the  disease  have  advanced  to  such  a  degree  as  to  make 
complete  removal  by  amputation  impossible,  and  the  patient's  forces 
be  not  profoundly  prostrated,  as  much  of  the  morbid  surface  should 
be  destroj'ed  as  possible,  by  some  procedure  not  involving  great 
danger,  in  the  hope  that  by  this  means  all  uterine  discharges  will 
be  diminished,  and  the  progress  towards  death  ~be  retarded. 

This  destruction  of  tissue  may  best  be  effected  by  strong  acid,  by 
the  galvano-caustic  knife  or  cauterizing  stem,  by  removal  of  the 
superficies  by  tenaculum  and  scissors,  by  scooping  it  out  with  a 
cutting  scoop,  by  charring  it  by  means  of  the  gas-jet  cautery,  or  by 
the  use  of  potassa  cum  calce. 

To  the  physician  practising  at  a  distance  from  a  large  city,  the 
most  attainable  and  efficient  of  these  means  is  the  thorough  and 
repeated  application  of  chemically  pure  nitric  acid.  To  apply  this 
the  cervix  should  be  exposed  by  a  large  glass  speculum,  which 
should  be  pushed  with  some  force  against  the  vaginal  junction,  to 
prevent  escape  of  acid  into  the  vagina.     The  cervix  should  then  be 


TREATMENT.  569 

cleansed  by  a  stream  of  cold  water  from  a  syringe,  and  thoroughly 
dried  by  dossils  of  lint,  or  bits  of  sponge.  Then  the  acid  should, 
by  means  of  a  glass  pipette  or  rod,  be  thoroughly  ap])lied  to  the 
whole  diseased  surface.  After  this  a  stream  of  water  should  be 
again  projected  upon  the  cervix,  and  a  pad  of  cotton  saturated  with 
glycerine  made  to  envelop  it.  This  produces  a  decided  slough, 
which  destroys  many  of  the  bloodvessels  that  have  proved  the 
source  of  hemorrhage.  I  regard  this  as  the  best  metliod  for 
accomplishing  partial  destruction  of  a  cervix  affected  by  cancer, 
and  now  resort  to  it  frequently  in  practice  with  excellent  results. 
Such  an  application  as  that  just  described  may  be  repeated  once  in 
two  or  three  months;  and  it  is  curious  to  see  how  patients  will 
urge  a  repetition  of  it.  I  can  fully  endorse  the  statement  of  Dr. 
Churchill,  who  thus  speaks  of  the  use  of  strong  nitric  acid  as  a 
caustic :  "  I  have  found  it  relieve  pain,  arrest  hemorrhage,  and 
restrain  the  discharges.  In  one  case,  hopeless  when  I  first  saw  her, 
life  was  prolonged  for  three  years  under  this  treatment." 

By  the  use  of  the  tenaculum  and  scissors,  as  much  of  the  tissue 
may  be  cut  away  as  can  be  effected  without  great  hemorrhage. 
Should  this  occur,  it  may  be  controlled  by  the  immediate  applica- 
tion of  persulphate  of  iron  in  weak  solution,  followed  by  a  tampon. 
Before  resorting  to  this  plan  it  is  well  to  employ  tampons  of  glyce- 
rine and  cotton  for  a  week,  in  order  to  disgorge  the  tissues  to  be  re- 
moved, and  secure  thorough  cleanliness.  As  the  tampon  is  removed, 
the  tissues  thus  treated  look  anaemic,  and  admit  of  removal  with 
less  hemorrhage  than  they  would  otherwise  do. 

The  method  of  scooping  out  these  growths  originated  with 
Simon,  who  employs  the  instrument  represented  in  Fig.  161  for 
the  purpose. 

Fiff.  161. 


i^^^^^^^^^& 


G.TI£MflNi\l  &  CD 

Simon's  scoop. 


Dr.  P.  F.  Munde^  thus  describes  this  process  :  "  The  object  is  to 
scoop  the  morbid  portions  out  of  the  normal  tissue,  by  means  of 
sharp,  spoon-shaped  instruments,  which  superficially,  and  in  cases 
of  large  prominent  tumors,  are  to  be  used  as  cutting  tools  ;  the 
deeper,  larger,  less  prominent  tumors  and  ulcers  are  to  be  merely 
scraped  out.     With  the  large  scoops  we  remove  the  bulk  of  the 


See  a  very  interesting  article  in  Amer.  Journ.  Obstet.,  Aug.  1872. 


570  CANCER  OF  THE  UTERUS. 

growth,  and  with  the  smaller  sizes  we  penetrate  into  the  various 
cavities  and  recesses."  The  operation  is  usually  so  painless  that 
no  anaesthetic  is  required.  This  ojoeration  might  with  advantage 
be  combined  with  the  application  of  nitric  acid. 

The  gas-jet  cautery  is  applied  by  means  of  a  metal  tube  attached 
to  one  of  gutta-percha,  which  connects  with  a  reservoir  of  the 
ordinary  gas  used  for  lighting  buildings.  Through  the  end  of  the 
metallic  tube  a  minute  jet  escapes,  which  being  lighted,  is  brought 
in  contact  with  the  morbid  growth  through  a  double  speculum 
between  the  walls  of  which  a  stream  of  cold  water  is  kept  circu- 
lating by  means  of  a  syringe  which  is  attached.  It  soon  destroys 
the  surface  entirely,  and  possesses  certain  advantages  not  attaching 
to  other  methods,  but  it  is  infinitely  less  manageable  than  the 
white  hot  iron,  and  can  only  be  employed  through  the  double 
speculum.  The  heat  generated  by  it  is  so  intense  that  a  single 
speculum  would  burn  the  vagina. 

Potassa  cum  calce,  which  consists  of  two  parts  of  lime  to  one  of 
caustic  potash,  or  two  of  the  latter  to  one  of  the  former,  as  Dr. 
Bennet  uses  it,  is  so  far  preferable  to  pure  caustic  potash  that  I 
shall  speak  of  it  to  the  exclusion  of  the  more  powerful  escharotic. 
It  was  formerly  used  as  Vienna  paste,  until  M.  Filhos  prepared  it 
in  the  form  of  a  stick,  at  the  same  time  rendering  it  much  more 
powerful  by  combining  two  parts  of  quicklime  with  one  of  the 
caustic  potash,  instead  of  from  thirty  to  fifty,  as  was  done  in  the 
paste.  A  large  cylindrical  speculum  having  been  introduced,  and 
the  cervix  cleansed  and  completely  dried,  a  dossil  of  cotton  soaked 
in  vinegar  and  squeezed  almost  dry  should  be  forced,  by  means  of 
the  long-shanked  speculum  forceps,  into  the  os.  A  large  supply, 
similarly  soaked  and  squeezed,  should  then  be  pressed  around  the 
neck  between  it  and  the  rim  of  the  instrument.  As  acetic  acid 
neutralizes  caustic  potash,  this  will  protect  all  the  tissues  which 
we  wish  to  avoid  injuring.  A  stick  of  caustic  should  now  be  taken 
in  the  grasp  of  a  caustic-holder  and  applied  to  the  cervix.  It  should 
remain  in  contact  with  one  point  for  from  five  to  ten  seconds,  then 
be  removed  and  brought  in  contact  with  an  adjoining  part  until  all 
the  desired  surface  is  cauterized. 

A  stream  of  fluid,  consisting  of  equal  parts  of  vinegar  rmd  water, 
should  then  be  repeatedly  thrown  against  the  cervix  by  the 
speculum  syringe,  a  piece  of  cotton  with  a  string  attached  and 
saturated  thoroughly  with  the  same  be  laid  against  it,  and  the 
speculum  removed.    After  this  the  patient  should  be  kept  perfectly 


TREATMENT.  571 

quiet,  and  pain  relieved  promptly  by  full  doses  of  opium,  by 
mouth  or  rectum ;  for  this  operation  is  sometimes  followed  by 
pelvic  cellulitis,  or  peritonitis,  and  I  have  in  one  case  known 
tetanus  occur  with  a  fatal  issue.  There  is  no  great  danger  of  these 
results ;  but  it  is  not  the  less  true  that  they  may  occur,  and  it  is 
the  duty  of  the  practitioner  to  be  forewarned  of  the  possibility. 
The  application  of  this  escharotic  should  always  be  regarded  and 
treated  as  an  oi^eration,  and  the  patient  should  distinctly  under- 
stand that  it  is  no  trivial  alFair,  to  be  lightly  dealt  with. 

Means  which  destroy  the  superficies  of  the  cancerous  mass  have 
a  decided  influence  in  controlling  hemorrhage.  It  may  further  be 
controlled  by  rest  during  menstruation;  astringent  vaginal  injec- 
tions ;  and  the  use  of  styptics,  by  suppositories  and  by  application 
to  the  bleeding  surface  upon  pledgets  of  cotton.  Should  the 
patient  employ  the  syringe,  the  most  appropriate  styptics  will  be 
the  sulphate  of  alum,  infusions  of  tannin  or  oak  bark,  or  a  solution 
of  the  persulphate  of  iron,  twenty  or  thirty  drops  to  a  pint  of 
water.  Should  the  practitioner  make  the  application  himself,  a  bit 
of  cotton  saturated  with  a  strong  solution  of  alum,  or  with  one  part 
of  solution  of  persulphate  of  iron  to  two  of  glycerine,  may  be  placed 
against  the  os.  In  doing  this  the  use  of  the  cylindrical  speculum 
should  be  avoided  if  possible,  for  its  introduction  always  tends  to 
excite  hemorrhage. 

The  relief  of  pain  should  be  accomplished  by  the  free,  unrestricted 
use  of  opium  by  the  mouth,  the  rectum,  the  vagina,  or  under  the 
skin.  I  often  encourage  my  patients  to  become  opium  eaters,  and 
urge  them  to  obtain  as  complete  relief  as  the  use  of  this  drug  can 
afford.  In  place  of  opium  other  narcotics  may  be  tried,  but  there 
is  none  which  compares  with  it  for  efficiency.  In  some  cases  the 
hydrate  of  chloral  in  scruple  doses  will  be  found  to  answer  an 
excellent  purpose,  either  as  an  alternate  or  a  substitute  for  opium. 
It  produces  sleep,  quiets  pain,  and  is  free  from  those  consequences 
which  frequently  render  opium  objectionable. 

When  opium  produces  the  painful  results  noticed  where  an  idio- 
syncrasy exists  against  it,  the  persistent  use  of  it  will  often  effect  a 
tolerance.  In  these  cases  the  hypodermic  use  of  morphia  often 
becomes  the  greatest  boon. 

It  is  wonderful  to  see  what  large  amounts  of  opium  may  be  con- 
sumed, not  only  without  danger,  but  Avith  absolute  benefit,  for  relief 
of  the  pains  of  cancer.  Pinel  is  said  to  have  administered  to  a 
woman  at  La  Charite,  120  grains  of  solid  opium  in  twenty-four 
hours  ;  Marc  allowed  a  patient  to  take  62  grains  of  morphine  in  the 


572  CAKCER    OF    THE    UTERUS. 

same  time;  and  Monges  and  La  Roche,  of  I'liiladelplna,  gave  three 
pints  of  laudanum  in  twenty-four  hours,  and  kept  up  its  adminis- 
tration at  this  rate  for  three  months.  Dr.  Knight,  of  Is'ew  Haven, 
had  a  patient  who  consumed  three  drachms  of  morphine  in  twenty- 
four  hours,  and  continued  the  use  of  this  drug  for  a  considerahle 
time  in  amounts  ahnost  equal  to  this.' 

The  fetor  of  the  discharges  may  be,  to  a  great  extent,  corrected 
by  the  use  of  vaginal  injections  containing  disinfectant  substances 
in  solution.  Solution  of  carbolic  acid  from  one  to  two  drachms  to 
a  pint  of  water,  Labarraque's  solution  of  soda  in  the  same  jiropor-  , 
tion,  one  drachm  of  powdered  pcrsul}>hate  of  iron  to  the  pint,  or  a 
weak  solution  of  the  iodide  of  lead,  will  prove  very  useful.  Of  all 
these,  carbolic  acid  is  the  most  certain  and  effectual. 

Coiistitational  Treatment. — Nothing  is  more  important  for  a  prac- 
titioner in  the  treatment  of  morbid  states  than  to  have  in  his  mind 
a  clear  and  distinct  line  drawn  between  those  means  which  repail  ( 
the  ravages  of  disease,  sustain  and  soothe  the  system  under  its 
deleterious  iniluences,  and  put  it  in  a  condition  to  allow  nature  to 
strive  for  recovery  on  the  one  hand  ;  and  those  which  by  some 
specific  action  cure  the  aftection  on  the  other.  A  confusion  of  I 
these  two  ideas  has  done  mischief  in  causing  hypermedication,  and 
in  creating  erroneous  conclusions  as  to  the  value  of  drugs.  In 
cancer  a  variety  of  drugs  have  at  various  times  since  the  birth  of 
Christ,  and  indeed  before  it,  been  vaunted  as  exerting  a  specific 
influence.  As  examples,  for  I  have  not  space  to  mention  one  tithe 
of  the  whole,  mercury,  iodine,  arsenic,  hemlock,  bromine,  gold, 
silver,  and  other  drugs,  have  had  their  day.  After  a  fair  trial 
having  been  given  to  each,  but  one  conclusion  can  be  drawn  by  a 
writer  of  the  present  time,  namely,  that  we  appear  to  be  as  far 
removed  from  the  discovery  of  a  cure  for  cancer  as  were  the  con- 
temporaries of  Hippocrates. 

The  general  strength  should  be  maintained  by  fresh  air,  residence 
in  the  country,  generous  food,  alcoholic  stimulants,  iron,  and  bitter 
tonics,  while  the  mind  should  be  kept  cheerful  by  lively  company, 
and  avoidance  of  the  society  of  those  who  encourage  conversation 
concerning  the  existing  disease.  As  the  digestion  is  weak,  the 
most  digestible  substances  shcmld  constitute  the  staple  diet,  and 
very  often  a  patient  who  will  become  emaciated  upon  solid  food 
and  a  mixed  diet  will  improve  upon  the  exclusive  use  of  milk,  beef- 


|:« 


'  Theso  facts  are  recorded  in   Dr.  Calkin's  valuable  work  on  "  Opium  and  the  ^ 
Opium  Habit."     Lippincott  &  Co.,  Philadelphia.  ! 


CONSTITUTIONAL    TREATMENT.  573 

tea,  and  similar  substances.  So  marked  is  this  fact,  that  the  milk 
i  diet  strictly  adhered  to  has  been  regarded,  by  many  non-professional 
persons,  as  a  means  of  cure  for  cancer.  Iron  should  be  freely 
administered  to  repair  the  damage  done  to  the  blood  by  those 
influences  which  establish  the  peculiar  cachexia  that  attends  the 
disease.  Quinine  answers  excellently  as  a  tonic,  a  general  roborant, 
and  a  remedy  for  the  neuralgic  pains,  which  are  often  exceedingly 
annoying. 

At  the  risk  of  becoming  tedious  by  repetition,  I  offer  the  follow- 
ing resume  of  the  methods  of  fulfilling  the  indications  in  treating 
this  affection. 

1st.  Secure  cleanliness,  prevention  of  fetor,  and  diminution  of 
\  hemorrhage  and  pain  by  the  free  use  of  tepid  vaginal  injections  of 
I  antiseptic  and  astringent  character,  such  as  the  following : 

R. — Acidi  carboHci    sol.  sat.),  ^ijss. 
Glycerinae,  Oj. 
Aluminis  sulphatis,  ^xiv. 
Morphiae  sulphatis,  gr.  xvj. — M. 
S. — Add  one  tablespoon ful  to  two  ([uarts  of  tepid  water,  and  use  as  a  vaginal  in- 
jection morning  and  evening  by  Davidson's  or  the  fountain  syringe. 

2d.  Give  an  abundance  of  food  lohlch  the  system  can  appropriate, 
at  regular  intervals,  bearing  in  mind  that  nutrition  consists  in  the 
i  introduction  into  the  blood,  not  into  the  stomach  alone,  of  nutrient 
materials. 

3d.  Do  not  indulge  in,  what  appears  to  be  to  a  certain  order  of 
iiiodical  mind,  the  grim  pleasure  of  making  a  fatal  prognosis.  As 
I  ting  as  possible  let  the  patient  enjoy  the  "pleasures  of  hope."  It 
i>  not  the  duty  of  the  physician  to  hold  constantly  before  her  eyes 
ilie  gloomy  picture  of  a  speedy  and  certain  death  which  he  is 
jiowerless  to  avert.  No  deception  should  be  practised,  and  none 
loed  be,  for  these  patients  always  suspect  the  truth  and  do  not  seek 
I »  be  informed.  Immediate  relatives  should  have  the  facts  plainly 
-hited  to  them. 

4th.  Quiet  pain  by  the  systematic  use  of  opium  or  one  of  its 
ilkaloids.  The  use  of  the  hypodermic  syringe  at  a  fixed  hour 
■very  day  is  the  most  certain  and  frequently  the  most  agreeable 
ilan. 
5th.  If  possible,  remove  the  diseased  part  by  electro-cautery. 
6th.  If  complete  removal  be  impossible,  and  the  vagina,  bladder, 
t'ctum,  or  pelvic  tissues  be  involved,  avoid  surgical  interference 
utirely. 


674  UTEKINE     MOLES. 

7th.  If  the  disease  be  confined  to  the  uterus  and  complete 
removal  be  impossible,  practise  partial  removal  or  destruction  of 
the  growth  by  galvano-cautery,  the  scissors,  scoop,  or  curette,  or  by 
actual  cautery,  faming  nitric  acid,  the  gas  jet  cautery,  or  potassa 
cum  calce. 


CHAPTER    XXXVI.  *, 

DISEASES  RESULTING  FROM  RETENTION  AND  ALTERATION  OF  THE 
F(ETAL  ENVELOPES. 

Uterine  Moles. 

Definition. — By  this  term  is  meant  the  existence  in  the  cavity  of 
the  uterus  of  a  fleshy  mass  which  cannot  with  propriety  be  classed 
among  tumors  or  polypi,  and  which  consists  in  the  retention  of  a 
part  or  the  whole  of  the  foetal  shell  or  of  the  placenta. 

The  appellation  of  mole  is  neither  elegant  nor  appropriate,  but 
it  is  sanctioned  by  use  for  so  great  a  length  of  time  that  it  is  difS- 
cult  to  alter,  and  impossible  to  discard  it. 

History. — Ancient  medical  literature  teems  with  theories,  hy- 
potheses, I  might  almost  say  fables,  upon  this  subject.  It  would 
be  unprofitable  even  to  enumerate  the  extravagant  and  baseless 
surmises  indulged  in  upon  it,  but  as  an  example  I  will  mention 
that  Aristotle,'  Hippocrates,  Galen,  and  the  Latin  authors  regarded 
moles  as  due  to  want  of  virtue  in  the  seminal  fl^uid,  or  to  a  super- 
abundance of  menstrual  blood. 

A  certain  superstition  has  attached  to  them  even  in  modern 
times;  thus  Capuron  quotes  Mahon  for  the  following  very  curious 
assertion.  "  The  housewives  believe  that  moles  not  only  take  the 
forms  of  certain  animals,  but  that  they  even  walk,  run,  fly,  try  to 
hide  themselves,  even  to  re-enter  the  womb  from  which  they  came; 
indeed,  if  no  obstacle  be  offered,  they  will  kill  the  woman  just 
delivered  of  them."  Levret  pointed  out  the  fact  that  they  are 
only  the  retained  foetal  shell,  which,  by  the  establishment  of  a  low 
grade  of  nutrition,  continues  to  exist. 

Pathology. — As  the  foetus  passes  into  the  uterus  it  is  enveloped 


'  Capuron,  Mai.  des  Femmes,  p.  268. 


PHYSICAL    SIGNS.  575 

by  its  proper  membranes,  tlie  amnion  and  chorion,  and  these  are 
surrounded  by  a  prolongation  of  the  hypertrophied  mucous  lining 
of  the  organ,  called  the  decidua  reflexa.  Between  the  end  of  the 
second  and  the  end  of  the  third  month  the  placenta  is  formed,  and 
the  villi  of  the  chorion  not  engaged  in  its  development  become 
atrophied.  Before  that  time  the  foetal  shell  is  quite  thick,  and  is 
everywhere  in  close  communication  with  the  uterine  walls. 

Many  adverse  inliuences  may  destroy  the  life  of  the  foetus,  and 
generally  as  a  result,  the  whole  of  the  products  of  conception  are 
swept  away  by  uterine  contraction.  But  sometimes  the  shell  of 
membranes  clings  to  its  attachment,  and  for  an  unlimited  period 
holds  its  position  in  utero.  This,  absorbing  nourishment  from  the 
uterine  vessels,  becomes  to  a  certain  extent  organized,  and  consti- 
tutes the  disease  under  consideration.  When  expelled  from  the 
uterus  a  mole  is  usually  found  to  be  somewhat  ovoid  in  shape,  and 
to  resemble  the  product  of  conception  at  the  second  month.  It 
differs  from  this,  however,  in  its  dark  brown  color  and  apparent 
lack  of  vitality. 

Causes. — There  are  many  intra-uterine  growths  and  collections 
which,  being  cast  oft",  may  be  mistaken  for  moles,  as,  for  example, 
masses  of  coagulated  blood,  polypi,  decidual  membranes,  etc.,  but 
it  is  very  doubtful  whether  a  true  mole  ever  exists  except  as  a 
result  of  conception. 

S]/mpfoms. — The  condition  generally  announces  itself  by  these 
symptoms : 

Menorrhagia  or  metrorrhagia ; 
Hypogastric  wei2;ht  and  uneasiness; 
Uterine  tenesmus ; 
Slight  constitutional  disturbance ; 
Cessation  of  signs  of  pregnancy. 

Physical  Signs. — The  diagnosis  of  uterine  moles  is  very  obscure 
md  often  uncertain.  When  a  patient  wlio  has  exhibited  all  the 
igns  of  pregnancy  suddenly  ceases  to  do  so  and  presents  those 
just  enumerated,  a  mole  may  be  suspected.  Vaginal  touch  will 
■(■veal  the  fact  that  tlie  uterus  is  enlarged,  and  the  uterine  prolie 
nay  assure  us  that  its  cavity  contains  some  solid  substance,  but  the 
(^■moval  and  examination  by  the  microscope  of  a  portion  of  the 
uass,  will  alone  enlighten  us  as  to  its  character.  The  condition 
•oing  suspected,  the  cervix  should  be  dilated  by  tents,  and  uterine 
-ction  excited  by  ergot  in  order  to  settle  the  question. 


576  CYSTIC    DEGEXEEATIOX    OF    CHORIOX. 

Differentiation. — This  disease  may  be  confounded  with 

Submucous  fibroid ; 

Sarcoma  or  cancer  of  the  uterine  body  ; 

Subinvolution. 

To  the  finger  passed  into  the  uterus,  a  fibrous  tumor  is  usually 
hard,  smooth,  and  resisting;  while  a  mole  is  soft,  spongy, and  yield- 
ing to  the  touch,  but  this  may  prove  deceptive. 

Sarcoma  and  cancer  may  he  known  by  the  peculiar  sensation 
yielded  to  touch,  their  fetid  discharges,  the  constitutional  depre- 
ciation attending  them,  and  their  microscopical  characteristics. 

Subinvolution  demonstrates  upon  exploration  the  fact  that  the 
uterus  is  empty.  It  also  frequently  follows  delivery  at  full  term, 
while  a  mole  rarely  does  so. 

From  all  these  conditions  the  differentiation  may  T)e  positively 
accomplished  in  one  way  and  one  way  only;  dilatation  of  the 
cervix,  removal  of  a  small  portion  of  the  mass,  and  examination  of 
this  by  the  microscope. 

Prognosis. — The  prognosis  is  favorable. 

Treatment. — The  cervical  canal  should  be  fully  dilated  and  an 
effort  made  to  arouse  uterine  contraction  by  persistent  use  of  ergot. 
Should  this  fail,  the  mass  should  be  cautiously  removed  by  the 
large  uterine  scoop,  or  by  traction  by  means  of  the  i»lacental  forceps. 

Cystic  Degeneration  of  the  Chorion,  or  Uterine  Hydatids. 

Definition. — The  chorion,  remaining  attached  to  the  uterine  walls 
after  expulsion  or  death  of  the  embryo,  sometimes  undergoes  a 
peculiar  metamorphosis  which  receives  this  appellation.  True 
hydatids,  that  is,  cysts  due  to  the  presence  of  the  acephalocyst,  are 
very  rarely  met  with  in  the  uterus.  Their  extreme  rarity  may  be 
judged  of  from  the  fact  that  Rokitansky  declares  that  he  has  never 
discovered  them  but  once.  Dr.  Graily  Hewitt'  believes  that  when 
they  exist  in  the  uterine  cavity,  it  is  probable  that  they  are  dis- 
charged into  the  peritoneum  from  rupture  of  a  cyst  in  the  liver, 
and  thence  pass  through  the  uterine  wall.  Not  only  do  the  grape- 
like cysts,  making  up  what  is  commonly  known  as  uterine  hydatids, 
differ  from  true  hydatids  in  absence  of  the  acei:)halocyst,  they  are 
also  unlike  them  in  their  appearance  and  formation.  The  former 
consist  of  little  sacs  in  a  series,  as  if  strung  together;  the  latter  are 
closed  sacs,  one  within  another. 

'  Op.  cit.,  p.  7r).  ', 


PATHOLOGY. 


577 


Synonyms. — This  aftection  has  been  described  under  the  names 
already  given,  and  under  those  of  vesicular  mole,  in  contra-distinc- 
tion  to  fleshy  mole  just  considered ;  hydatidiform  mole ;  and  hydatid 
pregnancy.    In  most  works  it  is  described  only  as  a  variety  of  mole. 

Pathology. — Remaining  in  connection  with  the  uterine  walls  after 
the  expulsion  of  the  foetus,  and  absorbing  nourishment  which  it  no 
longer  appropriates,  the  villi  of  the  chorion  undergo  a  kind  of  dro])- 
sical  swelling,  which  results  in  the  grape-like  bodies  styled  hydatids. 

Fiff.  162. 


d  .. 


Cystic  degeneration  of  chorion.     (Boivin  and  Dnges.) 

It  is  probable  that  after  the  end  of  the  third  month,  no  such 
degeneration  can  occur  in  the  secundines,  for  after  that  period  the 
placenta  is  formed,  the  villi  which  existed  at  its  site  become  vas- 
cular, and  those  over  other  parts  of  the  surface  of  the  foetal  sac 
undergo  atrophy.  It  is  true  that  at  parturition  at  full  term,  masses 
3f  these  sacs  have,  in  rare  instances,  been  expelled ;  but  in  such 
maes  it  is  probable  that  some  })ortion  of  the  chorion  had  begun  to 
legenerate  at  an  early  period  of  conception. 

Causes. — We  know  of  no  influences  which  excite  this  form  of 
legeneration  in  a  retained  chorion. 
37 


578  CYSTIC    DEGENERATION    OF    CHORION. 

Symptoms. — Sometimes  the  disease  demonstrates  its  presence  by 
all  the  signs  of  pregnancy,  abdominal  enlargement  being  one  of 
the  most  prominent.  Suspicion  of  the  existence  of  something 
abnormal  is  very  generally  excited  at  an  early  period  by  some  or  all 
of  the  following  signs : 

Nausea ; 

Discharge  of  clear  or  bloody  water ; 

Hemorrhage ; 

Uterine  tenesmus ; 

Constitutional  disturbance; 

Discharge  of  little  cysts. 

"Physical  Signs. — Vaginal  touch  will  reveal  the  uterus  enlarged, 
and  the  os  patulous,  as  if  the  cavity  of  the  organ  were  tilled  Avith 
something,  and  conjoined  manipulation  will  prove  this  to  be  fluid 
and  not  solid. 

If  with  these  signs,  the  fact  could  be  ascertained,  that  cysts  had 
been  discharged,  the  diagnosis  would  be  complete.  If  not,  the 
cervix  should  be  dilated,  in  order  that  tlie  cavity  of  the  body  may 
be  explored  by  touch,  or  that  a  portion  of  the  mass  may  be  removed 
for  inspection. 

Differentiation. — This  disease  might  very  readily  be  confounded  N 
with — 

Pregnancy ;  .  * 

Polypus ; 

Sarcoma  or  cancer  of  the  body  of  the  uterus. 

From  pregnancy  it  could  generally  be  distinguished  by  the  very 
rapid  development  of  the  uterus,  the  presence  of  watery  and  bloody 
discharges,  and  the  absence  of  quickening,  ballottement,  and  other 
signs  of  that  state. 

From  polypus  a  differentiation  could  readily  be  made  by  tents, 
the  uterine  sound,  and  the  microscope. 

Sarcoma  and  cancer  would  be  known  by  fetid  discharge,  great 
constitutional  decadence,  and  the  smaller  size  of  the  uterus  than  in 
hydatids. 

Prognosis. — If  the  case  were  one  of  true  hydatids  due  to  the 
acephalocyst,  the  prognosis  would  be  very  grave.  If  it  were  proved 
to  be  one  of  cystic  degeneration  of  the  chorion,  it  w^ould  be 
favorable. 

Treatment.— Hhe  treatment  should  consist,  1st,  in  full  dilatation 
of  the  OS  and  cervix  uteri  by  tents,  and  then,  if  necessary,  by 
Molesworth's  hydrostatic  dilators;   and,  2d,  in  excitation  of  the 


t 
1 


DYSMENORRHCEA.  579 

expulsive  powers  of  the  uterus  by  the  free  use  of  ergot.  Should 
this  drug  fail  in  establishing  the  desired  contraction,  a  large  scoop, 
or,  if  possible,  the  hand,  should  be  gently  passed  into  the  uterus, 
and  the  mass  be  evacuated.  During  this  time,  should  alarming 
hemorrhage  occur,  it  should  be  controlled  by  the  tampon  and  by 
tannic  acid,  or  sulphuric  acid  given  internally. 

In  the  management  of  such  cases  the  difficulties  do  not  lie  in  the 
way  of  treatment,  but  in  that  of  diagnosis.  This  being  once  fully 
established,  treatment  becomes  simple. 


CHAPTEH    XXXVII. 

DYSMENORRHEA. 

We  have  now  arrived  at  the  most  appropriate  place  for  the  con- 
sideration of  the  derangements  of  the  process  of  menstruation;  and 
first  among  these  we  take  up  that  of  which  the  name  heads  this 
chapter. 

The  process  of  menstruation,  by  which  the  human  female  dis- 
charges from  the  uterus  a  certain  amount  of  blood  once  in  every 
lunar  month,  depends  upon  three  phenomena  which  are  intimately 
connected  together :  1st,  the  spontaneous  escape  of  one  or  more 
ovules  from  the  ovaries ;  2d,  engorgement  of  the  erectile  vascular 
stratum  surrounding  and  supplying  the  uterus ;  and  3d,  rupture 
of  the  vessels  supplying  the  endometrium,  together  with  rapid 
desquamation  of  its  epithelial  cells.  Until  the  year  1821,  when 
Power  first  broached  the  subject,  the  connection  between  ovulation 
,  and  menstruation  was  unsuspected.  Even  then  it  was  not  estab- 
'lished  until  the  writings  of  Xegrier  in  1840.  After  this  the  in- 
j  vestigations  of  Pouchet,  Bi-^choff,  Coste,  and  Raciborski  carried 
'onviction  to  the  minds  of  most,  and  caused  the  general  acceptance 
:>f  tlij3  theory.  There  are  now  those  who  doubt  the  connection  of 
the  two  phenomena,  but  I  believe  that  I  am  correct  in  saying  that 
:hey  are  decidedly  in  the  minority,  and  that  the  ovular  theory  is 
it  present  almost  universally  admitted.  That  menstruation  some- 
:imes  occurs  after  removal  of  both  ovaries  I  know  by  experience 


580 


DYSMENORRHEA. 


in  one  of  my  own  cases  of  ovariotomy,  and  Dr.  Ritchie'  has  proved 
that  it  may  occur  without  ovulation,  as  ovulation  often  takes  place 
without  it.  But  this  is  not  the  time  for  an  examination  into  the 
merits  of  the  lengthy  discussion  which  has  taken  place  concerning 
the  subject.^  I  prefer  to  avoid  it  and  to  express  the  view  which  I 
believe  now  to  prevail,  and  to  which  I  give  my  own  adherence. 

"We  assume  then  that  the  extrusion  of  one  or  more  ovules  from 
the  ovaries,  which  takes  place  under  some  unknown  iniiuence,  is 
the  exciting  cause  of  menstruation ;  let  us  inquire  into  its  mode 
of  action.  The  uterus  is  surrounded  by  a  network  of  fine  and 
tortuous  vessels,  which  envelop  it  as  a  stratum  or  layer,  extending 
through  the  broad  ligaments  to  the  ovaries.  Outside  of  this  vas- 
cular network  delicate  muscular  fibres,  extending  from  the  uterus, 
run,  encircling  its  vessels.  AVhen  an  ovule  begins  to  approach 
the  circumference  of  the  ovary,  congestion  of  this  organ  occurs  in 
consequence  of  irritation.  This  irritant  efi^ect  is  transmitted  tO! 
the  muscular  layer  surrounding  the  vascular  network  in  and 
around  the  uterus.  It  contracts,  impedes  sanguineous  flow,  and 
causes  engorgement,  which  in  the  membrane  lining  the  uterus,  and 
in  all  probability  in  that  lining  the  tubes,  causes  a  rujiture  and 
flow  of  blood  into  the  uterine  caA^ity.  This  engorgement  consti- 
tutes the  "  erection"  alluded  to  by  Rouget  in  his  "  R^cherches  sul 
les  Organes  crectiles  de  la  Femme."  Blood  flowing  from  ruptured 
vessels  collects  in  utero,  whence  it  flows  through  the  cervix  into 
the  vagina  and  from  thence  it  passes  out  of  the  vulva. 

When  all  the  elements  connected  with  this  process  are  in  a 
perfectly  normal  state,  it  occurs  without  creating  other  discomfort  \ 
than  a  sense  of  fulness  about  the  [lelvis,  slight  pain  in  the  back 
and  loins,  and  a  general  sense  of  lethargy.  But  if  an  abnormal 
condition  should  exist,  either  in  the  structure  from  which  the  blood 
pours  into  the  uterus;  in  any  of  the  surrounding  parts  or  organs 
which  undergo  congestion;  or  in  the  canal  by  which  it  passes  into 
the  vagina,  menstruation  often  l)ecomes  excessively  painful,  and 
in  some  cases  undermines  the  health  by  the  intensity  of  suffering 
which  it  induces.  This  state  receives  the  name  of  dysmenorrhoea,  ■ 
a  term  derived  from  6d;,  diflicult,  fivjf^  a  month,  and  p^w,  I  flow. 

Falholog}/. — Any  condition,  whether  general   or  local,  afl:ecting 
the  structure  of  the  uterine  walls,  the  ovaries,  or  the  surrounding 


'  Ovarian  Physiology  and  Pathology. 
^  I  have  five  times  performed  double  ovariotomy.     In  four  of  the  cases  menstrnft-  >j 
tion  has  ceased.     In  one  an  occasional  metrostaxis  occurs.  II 


SEAT    OF    PAIN    IN    DYSMENORRHEA.  581 

areolar  or  serous  tissues,  so  as  to  render  the  nerves  supplying  these 
parts  morbidly  sensitive,  may  produce  pain  in  connection  with  the 
first  part  of  the  process.  Anything  impeding  the  escape  of  blood 
from  the  uterus  or  vagina  may  produce  it  by  interference  with  the 
second  part.  For  exam[)lc,  a  general  condition  resulting  in  neural- 
gia of  the  uterine  or  pelvic  nerves,  or  a  local  inflammation  altering 
their  state,  might  readily  create  pain  in  the  first  stage,  while  either 
a  natural  or  acquired  stricture  of  the  cervix  would  probably  do  so 
in  the  second. 

As  a  general  rule,  dysmenorrhoea  is  due  to  one  or  more  of  the 
three  following  factors :  1st,  a  depreciated  condition  of  the  consti- 
tution, beginning  usually  either  in  the  nervous  system  or  blood, 
which  creates  a  tendency  to  neuralgia;  2d,  an  abnormal  state  of 
the  uterus;  or  8d,  a  diseased  state  of  the  ovaries.  In  a  woman  in 
whom  the  nervous  system,  the  uterus,  and  the  ovaries  are  normal, 
it  is  highly  improbable  that  this  condition  would  ever  arise.  Every 
practitioner  can  recall  numerous  instances  in  which  any  one  of  the 
three  conditions  mentioned  has  sufficed  to  establish  it,  and  as  this 
is  true  of  each  of  them  separately  it  is  more  so  of  a  combination 
of  the  three. 

Every  case  should  be  examined  from  this  standpoint  in  practice, 
and  the  treatment  adopted  should  be  governed  by  the  discovery  of 
the  existence  of  one  or  more  of  these  conditions  as  causative  agents. 

Varieties  of  Dysmenorrhcsa. — For  convenience  of  study,  dysmenor- 
rhoea may  be  divided  into  the  following  varieties: 

Neuralgic  dysmenorrhoea ; 

Congestive  or  inflammatory  dysmenorrhoea; 

Obstructive  dysmenorrhoea; 

Membranous  " 

Ovarian  " 

Seat  of  Pain  in  Dysmenorrhmn. — Upon  this  point  our  knowledge 
is  not  certain.  It  is  probable  that  in  the  first  three  vtirieties  the 
pain  is  seated  in  the  uterus,  in  the  ovaries,  or  in  the  cellular  tissue 
»i-  peritoneum  surrounding  the  pelvic  viscera.  Some  of  the  most 
intractable  cases  with  which  I  have  met  have  been  due  to  pelvic 
peritonitis,  which,  even  after  inflammatory  action  has  subsided, 
las  left  the  nerves  supplying  these  parts  in  so  sensitive  a  state 
|"/hat  pain,  or  even  a  recrudescence  of  inflammation  styled  men- 
itrual  pelvic  peritonitis,  is  excited  in  them  by  the  process  of  men- 
strual congestion.      It  is  often  very  difficult  to  decide  as  to  the 


582  DYSMENORRH(EA. 

exact  seat  of  pain.     Even  a  physical  exploration  instituted  during 
the  menstrual  period  may  fail  to  enlighten  us. 

The  practitioner  who  regards  dysmenorrhoea  as  a  disease,  and 
applies  to  every  case  a  uniform  plan  of  treatment,  will  rarely  meet 
with  success  in  its  management.  Each  case  should  be  viewed  as  a 
symptom  of  an  abnormal  condition  which  should,  as  far  as  possible, 
be  discovered  and  removed.  Although,  even  when  acting  thus, 
cases  will  be  met  with  in  which  he  will  be  baffled,  it  will  be 
gratifying  to  perceive  how  rarely  these  will  occur.  The  great  im- 
portance of  dift'erentiating  the  varieties  mentioned,  and  adopting 
appropriate  plans  of  treatment,  calls  for  a  separate  study  of  each. 

Neuralgic  Dysmenorrhoea. 

This  variety  depends  upon  no  apftreciable  organic  disorder  of 
the  uterus  or  its  appendages,  but  merely  upon  a  peculiar  state  of 
the  nerves,  which,  under  the  stimulating  influence  of  congestion, 
produces  pain.  ■^ 

Causes. — There  are  many  agencies  which  at  times  so  alter  the 
healthy  state  of  the  nerves  of  the  stomach  as  to  produce  in  them, 
at  each  period  of  digestion,  pain,  whicli  is  called  gastralgia  or 
gastrodynia.  Similar  agencies  may  occasion  neuralgia  of  the 
nerves  of  the  eye,  or  of  those  sujjplying  the  tissues  of  the  head  I: 
and  face.  In  like  manner  they  may  affect  the  uterine  nerves 
whenever  these  are  inordinately  excited  from  menstrual  conges- 
tion. The  same  patient  who  from  slight  excitement  or  fatigue 
develops  supra-orbital  neuralgia,  will  often,  from  the  same  causes, 
suffer  from  neuralgic  dysmenorrhoea. 

The  causes  which  generally  induce  it  are — 

The  neuralgic  diathesis ; 

Chlorosis  or  plethora ; 

Certain  blood  states,  as  those  of  malaria,  gout,  and  rheuma- 
tism ; 

Luxurious  and  enervating  habits; 

Habits  deteriorating  the  nervous  system,  as  onanism  or  exces- 
sive venery. 

Symptoms. — Pain  may  show  itself  before  the  flow  has  been  estab- 
lished, and  disappear  as  soon  as  it  comes  on;  or  it  may  continue 
with  varying  intensity  throughout  the  duration  of  the  menstrual  .. 
discharge.  The  patient  usually  complains  of  a  sharp,  fixed  pain 
over  the  pelvis,  down  the  loins,  or  in  some  distant  part  of  the  body. 
I  once  saw  a  patient  who  during  each   period  suffered  intensely 


NEURALGIC    DYSMENORRHCE  A,  583 

from  neuralgic  pain  on  the  outer  side  of  one  little  finger,  and 
another  who  before  the  flow  was  established  experienced  for  several 
days  a  violent  pain  at  the  root  of  the  nose. 

Differentiation. — When  the  pain  is  felt  in  the  uterus,  it  presents 
nothing  expulsive  in  its  character ;  the  flow  of  blood  is  steady, 
and  not  interrupted  ;  no  clots  are  discharged  by  spasmodic  eftbrts, 
and  physical  examination  discovers  no  obstruction.  These  facts 
distinguish  neuralgic  from  obstructive  dysmenorrhcea. 

From  tlie  congestive  form  it  is  difl:erentiated  by  absence  of  con- 
stitutional disturbance,  by  its  gradual  and  not  sudden  occurrence, 
and  by  its  being  habitual  and  not  exceptional.  It  may  be  distin- 
guished from  the  inflammatory  variety,  by  absence  of  the  ordinary 
signs  of  endometritis,  and  of  ovarian  and  periuterine  inflamma-- 
tion.  There  is  also  absence  of  leucorrhoea  and  pain,  as  well  as  of 
the  physical  signs  of  inflammation,  in  the  intervals  of  menstruation. 

Prognosis.— If  a  patient  aficcted  by  neuralgic  dysmenorrhcea  be 
able  and  willing  to  eflfect  a  decided  alteration  in  her  mode  of  life, 
the  prospect  of  recovery  is  good.  Should  no  such  change  be  attain, 
able,  it  is  decidedly  unfavorable. 

Treatment. — The  first  duty  of  the  physician  should  be  to  discover 
the  cause  of  the  development  of  neuralgia  in  the  performance  of 
the  menstrual  function,  and  the  second  to  endeavor  to  remove  this. 
Neuralgia  of  the  face  and  head  is  rarely  a  primary  aftection,  and 
consequently  resists  remedies  directed  especially  to  it.  It  generally 
T-esults  from  some  focus  of  irritation,  as,  for  example,  a  decayed 
tooth,  or  a  plug  of  hard  wax  in  the  ear,  or  from  some  blood  poison- 
ing; and  when  the  cause  is  removed  it  disappears.  So  with  the 
disorder  which  we  are  considering.  If  the  rheumatic  or  gouty 
diathesis  exist,  it  should  be  treated  by  colchicum,  guaiac,  and 
vapor  baths.  The  skin  should  be  kept  warm  and  active  by 
wearing  flannel  over  the  whole  body  in  winter,  and  a  mild,  equable 
climate  should  be  chosen  during  the  cold  months  of  the  year. 
Should  a  delicate  state  of  the  nervous  system  have  been  engendered 
by  habits  of  luxury,  indolence,  or  dissipation,  the  patient  should  be 
sent  to  the  country,  where  an  out-of-door  life,  horseback  exercise, 
early  hours  of  retiring,  and  plain,  wholesome  food,  may  exert  a 
decidedly  alterative  influence.  Chlorosis  and  plethora  should  be 
treated,  the  one  by  ferruginous  and  nervous  tonics,  fresh  air,  food, 
and  cheerful  surroundings ;  the  other  by  strict  diet,  venesection, 
cathartics,  and  other  depletory  means.  Malarial  toxsemia  should 
be  treated  by  change  of  residence,  quinine,  and  iron.    A  sea  voyage 


584  DYSMENORRHEA. 

will  often  accomplish  an  excellent  result  in  neuralgic  dysmenorrhoea 
by  its  alterative  influence,  whatever  be  the  cause  of  the  neuralgic 
state. 

In  addition  to  these  general  means,  benefit  may  be  obtained  from 
the  use  of  some  which  are  local.  The  occasional  passage  to  the  fun- 
dus of  the  uterus  of  a  uterine  sound  or  silver  catheter,  the  retention 
in  utero  of  the  galvanic  pessary,  which  will  be  described  when 
speaking  of  amenorrhoea,  and  the  use  of  tents  of  sponge  or  sea-tangle 
will  often  prove  very  serviceable. 

Parturition  often  accomplislies  an  excellent  result,  and  in  many 
cases  cures  the  aftection  entirely. 

Besides  these  means  there  are  certain  anti-neuralgic  remedies 
which  act  more  or  less  as  specifics  in  this  form  of  dysmenorrhoea. 
Foremost  amongst  these  is  ai)iol,  a  3'ellowish,  oily  substance,  ob- 
tained from  the  petroselinum  sativum  by  the  action  of  alcohol 
and  filtration  with  animal  charcoal.  It  is  prepared  by  Joret  and 
Homolle,  of  France,  in  the  form  of  capsules,  and  is  sold  by  drug- 
gists throughout  this  country.  The  dose  of  these  is  one  capsule 
night  and  morning  during  menstruation.  The  tincture  of  cannabis 
indica,  in  doses  of  twenty-five  drops  every  fourth  hour  while  pain 
is  severe,  is  also  beneficial,  as  is  also  the  hydrate  of  chloral  in 
scruple  doses  every  eight  hours.  Where  a  spasmodic  element 
appears  to  exist  in  addition  to  the  neuralgic,  su[)positories  of  butter 
of  cocoa  containing  each  the  quarter  of  a  grain  of  extract  of  bella- 
donna will  often  give  great  relief;  they  should  not  be  repeated 
oftener  than  once  in  every  eight  hours.  Under  these  circumstances, 
too,  great  benefit  will  often  follow  the  use  of  enemata  of  tr.  of 
assafoetida,  two  to  three  drachms  in  a  gill  of  warm  water. 

Congestive  or  Iiifiammatory  DysmenoiThoea. 

Definition. — At  each  menstrual  epoch  an  active  congestion  occurs 
in  the  mucous  membranes  of  the  Fallopian  tuljes  and  uterus  as 
well  as  in  the  ovaries,  and,  probably,  to  a  less  degree  in  all  the 
pelvic  tissues.  When  any  abnormal  influence  renders  this  excessive, 
it  naturally  produces  pain  in  the  nerves  intervening  between  the 
distended  vessels.  This  excessive  hypersemia,  which  may  result 
from  a  mechanical  cause,  as  displacement  of  the  uterus,  or  from  a 
vital  cause,  as  the  peculiar  condition  which  we  know  as  inflam- 
mation, gives  rise  to  a  variety  of  painful  menstruation  which  has 
been  styled  congestive  or  inflammatory,  and  which  has  been 
synonymously  styled  accidental  in  contra-disti notion  to  those  forms 
which  are  habitual. 


CONGESTIVE    D  YSM  ENOEE  H(E  A.  585 

The  state  of  inflammation  wliicli  so  alters  the  condition  of  the 
nerves  immediately  aft'ected  by  ovulation  or  menstruation,  may 
exist  in  or  around  the  uterus,  in  the  peritoneum  covering  it,  in  the 
ligaments  which  sustain  it,  or  in  the  areolar  tissue  of  the  pelvis. 
r.  In  a  great  many  cases  inflammation  of  the  uterine  mucous  mem- 
brane is  the  cause  of  this  form  of  dysmenorrhoea.  The  existence 
of  disease  in  this  part  causes,  perhaps,  little  pain  until  the  erythism 
engendered  by  menstruation  occurs.  Then  great  local  excitement 
takes  place  and  dysmenorrhoea  allows  itself. 

Causes. — It  may  result  from  almost  any  pelvic  inflammation,  or 
from  any  influence  which  exaggerates  and  prolongs  the  congestion 
excited  by  ovulation.     Chief  among  these  may  be  mentioned — 

General  plethora ; 

Exposure  to  cold  and  moisture; 

Sudden  mental  disturbance; 

Sluggishness  of  portal  circulation; 

Displacement  of  the  uterus; 

Fibrous  tumors; 

Areolar  hyperplasia ; 

Endometritis ; 

Periuterine  cellulitis ; 

Pelvic  peritonitis. 

Some  of  these  causes,  even  without  exciting  true  inflammation, 
may  keep  up  a  state  of  hypersemia  in  the  uterine  vessels,  which, 
being  augmented  at  menstrual  epochs,  creates  pressure  upon  the 
neighboring  nerves  and  consequently  pain. 

Symptoms. — A  patient  who  has  previously  menstruated  painlessly 
is  seized  during  a  period  with  severe  pelvic  pain  accompanied  by 
diminution  or  cessation  of  the  discharge  and  considerable  consti- 
tutional disturbance.  The  pulse  becomes  full  and  rapid,  the  skin 
hot  and  dry,  and  the  eyes  suffused.  There  is  severe  pain  in  the 
head,  with  nervousness,  restlessness,  and  sometimes,  though  rarely, 
a  little  delirium.  There  may  be  in  addition  rectal  and  vesical 
tenesmus  and  diarrhoea.  In  cases  in  which  a  local  inflammation 
exists  as  the  flow  begins,  or  before  that  time,  the  patient  suffers 
from  dull,  heavy,  fixed  pelvic  pain,  which  lasts  until  the  process  is 
ended,  and  often  even  after  it  has  done  so. 

Differentiation. — If  the  attack  be  due  to  hyperemia  merely,  with- 
out inflammation,  the  constitutional  disturbance  and  suddenness 
which  characterize  it  will  mark  its  dift'erence  from  the  neuralgic 
and  obstructive  forms,  as  the  absence  of  signs  of  inflammation  in 


586  DYSMENOKRHCEA. 

the  intervals  will  do  from  the  inflammatory.  If  it  he  due  to  the 
influence  of  existing  pelvic  inflammation,  it  will  usually  be  marked 
by  pain  during  the  inter-menstrual  periods,  difficult  locomotion, 
fatigue  after  exertion,  leucorrhoea,  etc. 

Prognosis. — This  will  depend  upon  the  prognosis  of  the  condition 
which  has  given  rise  to  it.  If  that  can  be  removed,  the  dysmen- 
orrlioea,  which  is  one  of  its  symptoms,  will  disappear ;  if  not,  it 
will  continue  without  material  diminution.  If  the  cause  of  the 
symptoms  be  a  fibrous  tumor,  pelvic  peritonitis  or  periuterine  cel- 
lulitis, or  even  an  irremediable  displacement,  the  probability  of 
relief  is  of  course  not  at  all  great. 

Treatment— As  in  the  neuralgic  variety,  the  source  of  the  evil 
should  be  carefully  ascertained  before  remedial  measures  are 
adopted.  If  it  be  due  to  i)letliora,  the  lancet,  cathartics,  strict  diet, 
exercise,  and  fresh  air  will  be  indicated.  Should  the  attack  be 
accidental  and  have  occurred  from  cxjjosure  to  cold  and  moisture, 
opiates,  diaphoretics,  and  sedatives  will  give  speedy  relief.  In 
case  a  sluggishness  of  the  portal  circulation  exist,  this  should  be 
stimulated  to  greater  energy  by  mercurial  cathartics  and  a  change 
in  the  habits  of  life  from  sedentary  to  active.  A  displaced  uterus 
is  often  kept  in  a  constant  state  of  congestion,  which  can  be 
relieved  only  by  properly  sustaining  the  organ.  This,  according 
to  ray  experience,  is  the  most  frequent  of  all  the  causes  for  conges- 
tive dysmenorrlicca.  In  some  cases  a  slight  degree  of  retrovei'sion 
or  anteversion  will  produce  it,  while  in  others  direct  descent  will  be 
found  to  be  its  cause.  In  many  of  these  cases  it  will,  upon  recog- 
nition of  the  displacement,  be  scarcely  credited  by  the  practitioner 
that  it  is  suflicient  to  be  productive  of  the  result.  Yet  replace- 
ment of  the  uterus,  and  removal  of  superincumbent  weight  by 
means  of  a  skirt  supporter  and  abdominal  pad,  will  give  such 
complete  relief  as  to  put  all  doubts  at  rest.  If  a  fibrous  tumor  be 
the  cause,  a  cure  will  depend  upon  its  susceptibility  of  removal. 

Should  any  local  inflammation  be  discovered  as  the  cause  of  the 
evil,  this,  and  not  one  of  its  many  results,  should  be  the  subject  of 
treatment. 

OhstntHlre  Dj/sm en orrhoe.a. 

If,  after  the  collection  of  blood  in  the  uterus,  any  obstruction 
exist  which  prevents  its  escape  into  and  through  the  vagina,  a 
violent  spasmodic  pain  is  excited  which  often  amounts  to  uterine 
tenesmus.  To  this  form  of  painful  menstruation  the  name  of 
obstructive  dysmenorrhoea  has  been  applied.     The  obstruction  may 


OBSTRUCTIVE    DYSMENORRH(EA.  587 

exist  in  the  os  or  cervix  uteri,  in  the  vagina,  or  at  the  vulva,  where 
that  canal  is  partially  closed  by  the  hymen. 

Fathology. — If  any  organ  be  filled  with  fluid  beyond  the  point  of 
tolerance,  as,  for  example,  the  bladder,  stomach,  or  large  intestine, 
violent  contractions  of  the  distended  fibres,  which  make  up  its 
walls,  are  excited,  and  spasmodic  efforts,  which  have  received  the 
name  of  tenesmus,  are  established. ,  If  evacuation  result  from  these, 
relief  is  obtained ;  if  not,  contractions  continue  for  a  long  time. 
When  occurring  in  the  uterus,  they  present  the  symptoms  which 
characterize  the  affection  which  now  engages  us. 

Causes. — The  special  causes  of  such  obstruction  are — 

Congenital  or  acquired  contraction  of  the  cervical  canal ; 

Flexion  or  version  of  the  uterus ; 

Vaginal  stricture ; 

Small  polypus  in  utero  ; 

Obturator  hymen ; 

A  fibroid  in  the  parenchyma  of  the  neck. 

Any  one  of  these  causes  may  produce  the  result  by  partially 
occluding  the  cervical  canal,  so  as  to  allow  of  the  escape  of  fluid 
imperfectly  and  painfully.  Contraction  of  the  cervix  may  be  con- 
genital, or  may  result  from  inflammation  of  the  mucous  lining  of 
the  canal,  diminution  of  its  calibre  by  contraction  of  lymph  poured 
out  into  the  parenchyma,  or  from  the  use  of  strong  caustics  within 
the  OS.  The  last  cause  is  a  prolific  one,  the  condition  seldom  fail- 
ing to  result  from  the  passage  of  the  actual  cautery  or  potassa  cum 
calce  into  the  canal  of  the  cervix.  Flexion  obstructs  the  canal  by 
creating  an  angle  in  its  course.  Let  a  tube  of  gutta-percha  be 
slightly  curved  and  no  obstruction  will  exist,  but  if  it  be  sharply 
bent  upon  itself,  complete  occlusion  will  occur.  Versions  much 
more  rarely  produce  the  difficulty,  but  sometimes,  the  os  being,  by 
reason  of  the  displacement,  pressed  very  firmly  against  one  wall  of 
the  vagina,  a  partial  obstruction  is  produced. 

Some  time  ago  a  young  girl  presented  herself  at  my  clinique,  at 
tlie  College  of  Physicians  and  Surgeons,  declaring  that  at  every 
menstrual  epoch  she  suffered  from  the  most  intense  bearing-down 
pains,  which  exhausted  her  greatly.  Upon  examination  I  found  a 
partial  closure  of  the  vagina,  the  result  of  sloughing  during  typhus 
fever,  which  had  produced  an  accumulation  of  blood  above  it. 
This  excited  uterine  contraction,  and  each  effort  caused  the  expul- 
sion of  a  small  amount  of  the  fluid  collected  above  the  stricture. 


588  DYSMEXORRHCEA. 

In  like  manner  the  hymen  may  prevent  free  escape  and  produce 
uterine  tenesmus. 

Sometimes  a  small  polypus  comes  down  to  the  os  internum  and 
rests  upon  it,  obstructing  the  egress  of  fluid,  but  permitting  the 
passage  of  a  probe  into  the  uterine  body.  It  acts  upon  the  principle 
of  the  ball  valve,  and  by  so  doing  produces  the  worst  features  of 
obstructive  dysmenorrhoea. 

Symptoms. — After  menstruation  has  continued  for  some  hours, 
and  sufficient  blood  has  been  collected  in  the  uterus  to  distend  it, 
a  severe  spasmodic  pain  occurs  over  the  pelvis,  which  has  been 
styled  "  uterine  colic."  This  rapidly  passes  into  a  violent  expul- 
sive effort  like  the  contractions  attending  miscarriage,  which  in 
time  causes  the  passage  of  a  certain  amount  of  blood.  Then  severe 
pain  ceases  for  a  time,  until  further  distention  and  obstruction 
occur,  when  the  process  by  which  the  uterus  empties  itself  is 
repeated. 

It  will  be  clear  to  the  observer  that  the  difficulty  develops  itself 
by  these  steps : 

Ist.  Some  obstruction  causes  collection  of  blood  in  the  uterus ; 

2d.  This  excites  uterine  contraction  by  distention ; 

3d.  Uterine  contraction,  to  a  limited  degree,  frees  the  uterus 
and  gives  ease. 

This  is  the  pathology  of  the  condition,  whether  the  obstruction 
exist  in  the  vagina,  at  the  vulva,  or  in  the  cervical  canal.  If  it 
exist  at  the  latter  point,  the  eiibrts  of  the  uterus  will  generally 
expel  first  a  small  clot,  and  then  a  gush  of  imprisoned  blood  will 
follow,  much  to  the  patient's  relief. 

Differentiation. — The  symj^toms  just  related  are  so  marked  and 
decided  that  little  difficulty  will  generally  be  experienced  in  deter- 
mining as  to  the  pathology  of  the  case.  Before  such  a  decision  is 
arrived  at,  however,  physical  exploration  must  place  the  matter 
beyond  a  doubt.  The  absolute  obstruction  must  be  demonstrated 
by  difficulty  in  the  introduction  of  a  probe  into  the  cavity  of  the 
uterus.  Should  the  obstruction  exist  in  the  vagina,  the  finger  will 
detect  it,  and  if  in  the  cervix,  the  probe  will  do  so  with  almost  as 
great  precision. 

Prognosis. — This  will  depend  entirely  upon  our  ability  to  over- 
come the  mechanical  obstacle.  Should  it  not  be  possible  to  remove 
this,  the  constantly  repeated  distention  of  the  uterine  cavity  and 
consequent  effort  required  for  emptying  it,  will  frequently  result  in 
endometritis. 


OBSTRUCTIVE    DYSMENOREHCE  A.  589 

Treatment  of  Cervical  Constriction. — Slioukl  it  be  discovered  that 
the  cause  of  difficulty  consists  in  congenital  or  acquired  constric- 
tion of  the  cervical  canal,  the  condition  may  he  remedied  hy  two 
methods,  dilatation  and  incision,  the  means  for  accomplishing 
which  may  be  thus  presented  at  a  glance : 

Dilatation. 

By  sounds ; 

By  tents; 

By  expanding  instruments. 
Incision. 

Simpson's  method ; 

Sims's  method ; 

Combined  method. 

In  cases  of  cervical  constriction  unaccompanied  by  flexion  the 
narrowing  of  the  canal  is  much  more  marked  at  the  os  externum 
than  at  any  other  part,  though  in  some  instances  the  cavity  of  the 
neck  may  be  constricted  even  up  to  the  os  internum. 

About  the  year  1832,  Dr.  Mackintosh,  of  Edinburgh,  established 
the  practice  of  dilating  such  canals  by  metallic  rods,  as  is  done  in 
stricture  of  the  urethra.  His  [)lan  was  to  introduce  a  verj  small 
sound,  leave  it  for  a  short  time  in  position,  and  then  follow  it  by 
others  gradually  increasing  in  volume.  He  declares,  in  reporting 
upon  the  practice,  that  out  of  twenty-seven  cases,  twenty-four  cures 
were  eflected.  The  sounds  by  which  dilatation  may  be  best  accom- 
plished are  graduated  ones  of  metal  of  three  or  four  sizes.  Those 
of  Kammerer  are  very  convenient.  Dilatation  by  their  means  should 
l)e  slowly  and  cautiously  accomplished.  A  sound  being  passed 
should  be  left  in  position  for  several  minutes,  and  upon  its  removal 
another  should  be  inserted,  until  the  distention  deemed  practicable 
at  one  sitting  is  attained.  There  can  be  no  question  as  to  the 
efficacy  of  this  plan,  though  it  is  probable  that  some  of  the  cases 
relieved  by  Dr.  Mackintosh  were  instances  of  neuralgic  and  not 
rhstructive  dysmenorrhoea. 

The  same  result  may  be  accomplished  hy  the  use  of  tents  of  sej-  • 
langle  or  sponge,  but  the  danger  attending  this  method  should 
always  be  considered  before  it  is  selected. 

Another  method,  which  has  been  adopted  with  advantage  in 
j  many  cases,  consists  in  the  dilatation  of  the  constriction  by  moans 
I  of  expanding  instruments.     One  of  the  best  of  these  is  shown  in 
Fig.  163. 

A  modification  of  Holt's  stricture  dilator  is  likewise  employed 


590 


DYSMENORRHOEA. 


for  this  purpose.  The  action  of  these  instruments  is  too  injurious 
to  the  tissues  to  he  safe,  and  they  are  by  no  means  so  promising 
of  good  result  as  the  use  of  cutting  instruments. 

Fig.  163. 


Priestly's  dilator  for  the  cervix. 


Ir  1843,  Prof.  Simpson,  of  Edinburgh,  advocated"  and  practised 
cutting  through  the  walls  of  the  cervix,  and  thus  gaining  space 
without  dilatation.  He  employed  a  single-bladed  hysterotome, 
represented  in  Fig.  1G4. 


Fiff.  164. 


Simpson's  hysterotome. 

This  instrument  is  introduced  without  a  speculum,  the  patient 
lying  on  her  left  side.  The  hysterotome,  with  its  blade  concealed, 
is  guided  by  the  index  finger  up  to,  and  if  necessary,  as  is  very 
rarely  the  case,  through  the  os  internum.  If  the  cervical  canal  be 
too  small  to  admit  it,  previous  dilatation  should  be  practised  by 
tents.  Being  placed  in  position  the  blade  is  thrown  out,  the  force 
being  increased  as  it  is  withdrawn  to  the  os  externum.  By  thus 
increasing  the  pressure  upon  the  handle  of  the  blade,  the  incision 
is  made  wider  at  the  loAver  than  at  the  upper  part  of  the  canal. 
The  instrument  is  then  reintroduced  and  the  other  side  incised  in 
a  similar  manner,  and  the  surface  is  brushed  over  with  the  solution 
of  persulphate  of  iron. 

To  accomplish  the  incision  of  both  sides  simultaneously,  a  number 
of  double  hysterotomes  have  been  devised  with  two  blades  instead 
of  one.  That  of  Dr.  Greenhalgh,  of  London,  has  become  popular. 
A  very  simple  one  devised  by  Mr.  Stohlmann,  of  this  city,  is  repre- 
sented in  Fig.  16o. 

Since  Dr.  Simpson  introduced  this  plan  of  treatment  several 
modifications  of  it  have  been  recommended,  but  very  little  im- 
provement had  been  attained  until  the  introduction  of  Dr.  Marion 
Sims's  method.     This  consists  in  the  following  steps: 


OBSTRUCTIVE    D  Y  S  M  EN  ORRH(E  A.  591 

1st.   The  patient  is  placed  on  the  left  side  and  the  speculum 
introduced. 

Fig.  165. 


Stoblmann's  bysterotome. 

2d.  The  uterus  being  fixed  by  a  tenaculum,  one  wall  of  the 
cervix  is  cut  with  a  pair  of  long  scissors,  one  blade  of  which  is 
passed  into  the  cervical  canal  until  the  other  reaches  nearly  to  the 
vaginal  junction.     In  like  manner  the  other  wall  is  incised. 

3d.  The  blood  being  washed  away  by  sponge  probangs,  a  blunt- 
pointed  knife,  which  can  be  placed  at  difterent  angles  with  its 
handle  by  a  movable  joint,  already  shown  in  Fig.  124,  is  passed  up, 
tlie  tissue  above  the  reach  of  the  scissors  cut,  and,  if  it  be  deemed 
necessary,  the  os  internum  severed  on  each  side. 

4th.  A  roll  of  carbolized  cotton  saturated  with  glycerine  is  put 
into  the  wound,  and  a  vaginal  tampon  applied. 

The  patient  should  be  kept  in  bed  for  a  fortnight  after  the  o[ie- 
ration.  In  twenty-four  hours  the  tampon  should  be  removed,  and 
on  the  third  day  the  lips  of  the  w<uind  should  be  separated  l^y  a 
sound,  and  the  carbolized  cotton  dressing  reapplied.  This  should 
then  be  done  every  second  day,  or  the  cervix  will  rapidly  contract 
and  become  as  small  as  before  the  operation. 

The  results  of  incision  of  the  cervix,  when  practised  in  suitable 
cases,  are  sometimes  very  gratifying.  In  cases,  however,  in  which 
the  cervical  tissue  has  undergone  atrophy,  or  become  hard  and 
contracted,  it  is  often  impossible  to  keep  the  canal  pervious.  It 
gradually  contracts  in  spite  of  all  that  can  be  done  to  oppose  its 
doing  so. 

A  very  simple  and  useful  modification  of  the  operations  of 
Simpson  and  Sims  is  to  make  a  very  superficial  incision  through 
the  submucous  layers  of  the  parenchyma  from  the  os  internum 
through  the  whole  course  of  the  canal,  and  place  within  the  canal 
a  roll  of  cotton  saturated  with  a  weak  solution  of  persulphate  of 
iron.  This  may  be  allowed  to  remain  in  place  for  forty-eight  or 
fifty -six  hours.  At  the  end  of  a  fortnight  it  may  be  replaced  by  a 
.^tem  of  glass  or  vulcanite. 


592  DYSMEXORRHCEA. 

This  procedure,  wliicli  I  very  much  prefer  to  either  of  the  otliers 
mentioned,  may  be  accomplished  by  the  use  of  a  long  narrow- 
bladed  bistoury,  or  by  such  a  hysterotome  as  that  represented  at 
Fig.  166. 

Fi<?.  166. 


Wliite's  hysterotoiut'. 

This  instrument  was  invented  fifteen  years  ago  by  Dr.  Octavius 
White,  of  this  city,  and  has  been  frequently  employed  since  by  a 
number  of  practitioners.  Being  introduced  up  to  the  os  internum, 
two  blades  are  thrown  out  by  an  action  governed  by  a  screw  at  the 
end  of  the  handle,  and  it  is  then  withdrawn. 

Nothing  makes  the  results  of  section  of  the  uterine  neck  so 
successful,  and  as  fully  prevents  subsequent  contraction,  as  the 
maintenance  within  the  canal  of  a  stem  of  glass  or  vulcanite.  It 
is,  however,  difficult  to  keep  such  a  stem  in  place,  and  I  refer  the 
reader  to  Fig.  130  for  a  plan  by  which  I  have  readily  succeeded 
in  accomplishing  it. 

The  stem  should  measure  two  inches,  and  consequently  cannot 
reach  the  fundus.  By  its  base,  which  is  globular,  it  rests  in  a  cup, 
which  is  fixed  between  the  bars  of  a  small  retroversion  pessary. 
This  stem  tilts  forwards,  backwards,  and  laterally,  under  pressure, 
so  that  it  moves  freely  in  every  direction,  and  does  not  resist 
change  in  position  of  the  uterus,  but  merely  keeps  its  place  within 
the  neck.  The  stem  of  this  instrument  may  be  made  of  glass,  vuU 
onnite,  or  pewter,  and  of  any  size  desired.  As  constriction  of  the 
uterine  neck  is  often  accompanied  by  flexion,  the  use  of  an  'ante- 
flexion pessary  for  the  support  of  the  stem  often  answers  a  good 
purpose  in  overcoming  that  condition. 

Treatment  of  Cases  Dependent  upon  Flexion  or  Version. — Sliould 
version  be  the  cause  of  dysmenorrhoea,  it  should  be  relieved  not 
by  o])cration,  but  by  the  means  already  mentioned  when  speaking 
of  that  displacement.  If  the  difficulty  be  duo  to  flexion,  and  more 
particularly  to  anteflexion,  tAvo  indications  ofter  themselves  for  its 
relief:  1st,  to  straighten  the  bent  canal  by  keeping  the  body  of 
the  uterus  erect;  2d,  to  efliect  the  same  end  by  surgical  operation. 


'  It  is  necessary  that  T  should  state  that  the  nse  of  this  instrnmenl  requires  some 
praetice  and  skill.  T  always  select  a  small  pessary  and  apply  it  throufjh  Sims's 
speculum.     "Without  this  speculum  I  doubt  the  possibility  of  using  it. 


MEMBKANOUS  D  Y&MENORRHCE  A.  593 

If  a  uterus  be  flexed  below  tbe  vaginal  junction,  it  is  evident 
that  obstruction  to  the  menstrual  flow  will  occur  at  the  point  of 
flexure,  and  equally  evident  that  an  incision  through  both  sides  of 
the  canal  would  not  overcome  this  bj  straightening  it,  while  a 
single  incision  through  the  posterior  wall  would  do  so.  In  1862, 
Dr.  Sims  conceived  and  practised  such  an  operation  successfully. 
This  will  be  found  described  in  the  chapter  on  flexion.  It  is 
unquestionably  the  procedure  most  applicable  to  the  relief  of 
dysmenorrhoea  due  to  anteflexion. 

TreMtment  of  Vagir.nl  Stricture. — This  condition,  which  may  be 
congenital,  or  be  induced  by  syphilitic  or  cancerous  disease,  or  by 
sloughing,  if  so  complete  as  entirely  to  obstruct  the  canal,  pro- 
duces amenorrhoea.  If  it  be  a  pervious  stricture,  it  may  result  in 
dysmenorrh(3?a. 

The  aftection  maybe  treated  by  three  methods:  dilatation  by 
large  bougies,  dilatation  by  tents,  and  incision.  If  syphilis  be 
ascertained  to  be  the  basis  of  the  local  disorder,  constitutional 
means  should  at  the  same  time  be  resorted  to. 

Treatment  of  Di/sinenorrhoca  from  Poli/pus. — Should  the  presence 
of  a  small  polypus  l)e  discovered,  the  cervix  should  be  dilated  by 
tents  and  the  growth  removed. 

Treatment  of  Obturator  Hymen  and  Fibroids. — The  first  should  be 
incised  with  extreme  caution,  and  the  second  removed,  if  possible. 

Membranous  JDysmenorrhma. 

Definition. — This  variety  of  dysmenorrhoea  consists  in  the  expul- 
sion of  organized  material  from  the  uterine  cavity,  at  menstrual 
periods,  which  is  found  u[)on  microscopical  examination  to  consist 
of  the  lining  membrane  of  the  uterus  itself.  This  may  consist  of 
a  sac,  representing  the  triangular  cavity  of  the  body  of  the  uterus 
with  its  three  o[)enings,  or  it  may  come  away  piecemeal  as  shreds 
or  strips  of  mucous  membrane. 

Observers,  since  the  time  of  !Morgagni,  have  recognized  this 
form  of  disordered  menstruation,  but  looked  upon  the  mould  cast 
ofl"  as  formed  of  false  membrane,  and  as  being  a  result  of  croupy 
r>r  diphtheritic  endometritis.  For  the  true  exj)lanation  of  the  phe- 
nomenon we  are  indebted  to  Simpson,  Oldham,  and  Virchow. 

Pathology. — Dr.  Oldham's  opinion,  which  strikes  me  as  the  most 
rational,  not  only  upon  theoretical  grounds,  but  from  close  obser- 
vation of  those  cases  which  have  come  under  my  notice,  is  that 
it  some  time  during  the  intermenstrual  period,  the  entire  lining 
nembrane  of  the  uterus  is  lifted  from  its  base  and  separated,  so 
38 


501  DYHMKNO  ItUIKKA. 

jiH  lo  I»(i  rvuAy  I'or  cxI  riiKioii  nl  o\w.  of  tlio  next  moriRfrnul  oriHOH. 
Vii'cliovv  (IccliircM  lliiil  ii  (IccidiioiiM  iii('iiil)nnu',  Hiiiiiljir  to  tli;i(.  of 
|irc!;'iiiiiicy,  foriiiH,  iiinl  foi-  Mils  iii('iiil)r'iiiu!  lie  |ii'()|(os('S  (lie  iiiiiiic 
ol"  llid  "  iim'IihI mill  (Iccidiiii."  I>r.  Oldliiiiii  lidicvcd  (liiii  congcs- 
lioii  of  (lie  oviirii'H  i;jiv(i  ris(?  (o  (his  rcin:irkiil»Ui  ]»1i('11()iiu'Iiom,  by 
IriiiiHinil  (iiii;- nil  Irriliiiil  inlliiciifc  (o  (lie  uterus.  1  lowcvfi-  iuiiut!:u- 
nilcd,  (Ills  procrHH  ji|)[)OJirH  (o  prciuiro  tlu)  JiuMuhruuo  griidiially  for 
('oiii|il('((i  <l('(:icliiii('ut  mid  cxtnislon  iit  n  uicustruiil  pcfiod,  \vlu;ti 
i(  is  expelled.  Siiu|isoii,  deny  iiiL!,"  ( lie  eiiusadve  iullueiiee  ot"  iiidani- 
iniiddii  ill  (lie  |ii()dii»l  ion  of  ( lie  niciist  rual  dceidua,  reuai'ds  it.  a« 
it  |tfo(lu«'(  iiadirai  to  (lie  uterus  as  (o  fuiiedoii,  l>u(  iiiiiiadiral  as  to 
time,  eii'euuis(auees,  and  fn(|ueuey  of  development. 

All  eii(ir('  iiifiiiliraiious  eas(,  wlieii  washed  and  examined  hy  tlio 
naked  eye,  is  found  (o  he  t  riaui;ular,  with  three  openiu!j,s,  two  at 
its  u|»per  aiiu'les  and  oik*  at  its  lower.  Its  exlei'ual  face  is  soft  and 
irri'ju'ular,  and  eveiy  wliei"(>  shows  Hiiiall  p<  rforat  ions,  which  are 
opiMiiui^'s  of  u(rieular  follicles.  The  inner  faee  is  frei'  from  ine([ual- 
i(ies,  and  feels  like  mucous  memhraiie.  'riies«>  saes  are  usually 
exd'uded  as  (luy  lie  in  utero,  hu(  sometiiiU'S  tlay  are  iiuerted. 
in  one  insiaiiei'  1  lia\e  known  such  a  sac  to  hecoiiu'  invei'ted  and 
expelled  in(o  I  he  vagina,  hu(  the  eervieal  extremity  holdiui;-  its 
allachment  at  (he  os  internum,  (he  inviM'ted  hai:;  hun«i-  like  a  ]>oly- 
pus  in  the  \a^ina.      A  similar  casi'  is  recorded  hy  Mine.  Hoivin. 

I'lahM'  tlu>  nTu'roscope  the  east  is  touud  to  consist  «>f  tlu>  lining 
nuMuhi'aut'  of  the  uteiais,  liypei't rophied  in  all  its  elements  almost 
(>xae(lyas  i(  is  in  pre^naiuy.  linlecd,as  1  shall  soon  show,  tlie 
most  skilful  mieroseopist  cainiot  distiuiiuish  one  from  tlie  other.  I 
'V\\o  vessels  (if  tlu*  mucous  memhi'an(>  are  inereas(>d  in  size,  capacity, 
and  niimher,  a  prolilei'ation  has  takt>n  pkn-e  in  its  epithelial  et'lls, 
and  siieat  de\elo|)ment  has  occurred  in  (lu>  utriculai"  u'hinds,  the 
mouths  t)f  which  are  visihle  e\eu  lo  the  naked  i-ye. 

.K(iolo(/i/.  'Phis  part  {^\'  our  suhjeet  constitutes  one  ot"  its  most 
impor(an(  and  in(crest  iu^;-  points,  hut ,  unfor(  unately,  that  divci*sity 
ol"opiniot\  whii'h  always  eharactiM-i/.es  unsettled  (|ui>stions  is  t'ound 
to  <*xis(  here.  Our  want  ol'  accurate  informal i»>n  (K'peiids  upon 
the  fact  that  tlu>  true  pathology  of  tlu'  I'ondition  is  not  known. 
Sotne,  with  (>ldham  and  'Pilt,  reo-anl  it  as  a  result  o{'  ovarian  dis- 
ease; tMhers,  with  Kacihorski,  Lehert,  llandticld  Jones,  ami  Simp- 
son, l(»ok  upon  it  as  a  pure  des(|uaniatlon  or  exfoliation  yA'  the 
uterine  mucous  nn>mhrane  for  whii-h  m>  cause  can  he  assii^nod; 
while  KU>h  and  others  are  convinced  that  it  is  an  cxmlation,  the 
result  ot'  endometritis,  thus  returning  to  the  position  assumed  by 


M  10  M  n  U  A  N  ( )  r  S     I )  N'  S  M  K  N  O  K  1!  1 1  (K  A  .  .M)!') 

our  rort'lht  lu'i'M.  In  I'lirtlifi-  I'd'crcncc  l<>  d  iolo^-j  I  mIkiII  i;i\'(>  u  rf- 
.siiinc  o['  (lie  vu'vvs  wliicli  Iiiinc  lu-cii  iiiid  jii'c  rcc«'i\'('(l,  iiml  mciilioii 
Moiiic  ol"  (lio  iuil  lioril  ics  who  iulluTo  to  llicm. 

1.  It  \v;iM  loniu'rly  believed  t  li;il.  n.  liiver  of  |il:isl  ie  lviii|p|i  \\:is,  iin 
;i  I'esiill  of  eiuloiiiel  ril  is,  llirowii  oiil  over  llie  iileriiie  wiill,  wliieli, 
Ix'coiuiui;"  ori;iini/eil,  eoiisl  i(  iiled  (lu^  ensi  kA'  I  lie  iilenis.  ThiM 
Ixdief  w;iH  enrerliiiiied  Ity  Moiil  <;'oiiK'i-y,  hewees,  Siehold,  l*'i':ink, 
Niii'i;"elo,  I  )esoniie:iii\,  ;iiid  olliern. 

l!.  1 1  in  now  rei:«;jird(.>(l  as  nn  exlolialioii  of  Hie  eiilire  nnieoiis 
nieinhraiie  ol"  llie  iileriiie  hodv,  diii^  lo  eoiii;'es(  ion  and  irrilalion 
I  raiisniil  led  lo  llie  iilerns.  'Pliis  \iew,  conceived  \^\  Oldliani,  is 
adhered   lo  hy  Senielaii;iie  and  olliers. 

J5.  'The  jtalhoio^ieai  explaiialion  jnsl  menlioned  heiiii:;  iidoplcd, 
Ihe  cause  of  llu^  occurrence  of"  llu^  exlolialion  is  allribnlcd,  in  I, he 
words  ol"  Scanz-oni,'  l<»  "a  <'onsi(leral)le  hvpern'mia.  of  Ihe  walls  ol" 
Ihe  nlcrus,  wliich  is  rollovved  hy  an  excess  in  Ihe  de\('lo|iiiiriil  ol" 
Ihe  nnicous  inenihraiie."  'riiislheory  is  adopled  hy  <'oiirl\\  lii-jjar, 
iCii^'enhrodl ,  and  others.  The  lasl,  I  wo  a  nl  horil  ies  lia\'e  |iro|»osed 
for  it  (1k!  niiino  of  "dysMienorrIi(ea,  jip()|ileclica/'" 

•1.  I'rol',  Sinipsoir' all  rihnlcd  Ihe  exfolial  ion, 'Mo  an  exai';i;'eralioii 
ol"  a  normal  condilion,  or  Itt  an  exalled  de<j;ree  ol"  a.  ithysioioj^icid 
aclion."  Mandl  declares  I  hat  K'okilansky,  K'ohln,  May<'r,  and 
olliers  ji(h)|il.  this  view,  lie  lurlher  allrihnles  Ihe  sanu^  helieC  lo 
Kloh,  ('Oiii'ty,  and   l>raiin,  hnl  in  this  I  lhiid<  thai.  Ik^  is  in  error. 

5.  1 1,  is  I'c^a  rded  as  due  lo  an  innainnialory  coinlil  ion  hy  Kloh,' 
who  dcclai'es,  that  ''those  ]ial  lioloL;isls  werc^  not  far  I'roni  llu^  trnlh 
who  descrihed  such  (tascs  as  endonietrilis."  This  view  iw  endorsed 
hy  Tilt,''  r>raiiii,'''  and  others. 

(!.  |{y  some  tla^  nieinhraiK^  is  rci^'arded  as  due  lo  a  deciduous 
forniation  excited  h)'  conception  which  has  just  heeii  eslahlished, 
or  is  ovidai"  in  ils  cliaract<'r.  Tlui  lirst  ol"  these  views  is  niainlained 
hy  lljiUHMian,^  and  admitted  in  some  cases  hy  ivokitaiiHky  ;\iiid  tlio 
-second  waH  jidvaiuted  hy  Racihorski. 

From  my  obmu'Vittioii  (>r  this  nU'ection    I   cannot  allrihut(i  it   lo 


'  Op.  cit.,  p.  a-lft. 

"  for  my  citat.inn  dC  iiiilliorilii'S  on  liiiM  milijcd,  cKiicciiUiy  Mkh-k^  nl"  (ii'i'iinuiy,  I 
■fly  npi)ri  a  v(!ry  viiliiiiltUi  iirtiolo  liy  I»r.  Miiiidl,  of  Viciinn,,  tnuiHliilcti  in  l.lio  N.  Y. 
)I)hI(iI,.  .lourii.,  vol.  ii,  p.  A{)'l.     To  MiiH  cKHiiy  1  iim  iiiiicli  iiidciiliMl. 

•'  Clin.  Lrcl,  on  Din.  of  VVoiim'ii,  Am.  cit,  p.  Id!). 

"  Op.  cil.,  p.  2:n.  <■'   LiuKUil,,  \HW.\. 

"  i'lxprcHsion  of  opinion  in  Dr.  MiuidrH  vnw..     Hcd  IiIh  lU'licIo,  p.  A\'.\. 

'   Miindl'M  iirticic,  p.  ^1(17.  "   K  loh,  oj..  cil..,  p. '2:{7. 


596  DYSMENOERHCEA. 

endometritis,  for  evidence  of  tbo  existence  of  that  disease  was 
entirely  wanting  in  four  cases  out  of  five.  Even  if  endometritis 
exist  wntli  marked  displacement,  it  must  not  be  concluded  that 
these  conditions  have  necessarily  i)roduced  exfoliation,  for  they  are 
commonly  present  as  results  in  eases  in  which  dysmenorrhoea  of 
membranous  type  has  lasted  long  without  evidence  of  their  exist- 
ence. 

Frequency. — I  cannot  regard  the  disease  as  one  of  frequent  occur- 
rence, for  in  my  experience  I  have  met  with  it  but  five  times.  It 
is  true  that  I  have  seen  a  number  of  cases  which  had  been  regarded 
as  of  this  character,  but  most  of  them  proved  not  to  be  so  u]wn 
closer  examination.     Scanzoni  reports  twenty-one  cases. 

Differentiation. — The  diseases  with  which  this  may  be  confounded 
are — 

Early  abortions ; 

Blood  casts,  or  fibrinous  moulds  of  the  uterus; 

Exfoliation  of  the  vaginal  mucous  membrane; 

Dii)htheritic  endometritis. 

From  the  first  of  these  the  differentiation  can  be  accomplished 
by  the  jDrogress  of  the  case,  the  repetition  of  tlie  process,  and 
the  entire  absence  of  the  symptoms  of  i;regnancy.  The  great 
difiiculty  which  attends  determination  of  the  character  of  one 
specimen  may  be  gathered  from  two  quotations  from  Dr.  Mandl's 
article  already  often  alluded  to.  Tliey  are  from  reports  by  AVedl 
and  Eokitansky,  who  ex\'OBe^  spciimcns  from-  tlic  same  patient  to  the 
microscope.  Wcdl's^  report  ends  in  these  words:  "This  proves 
that  the  membranes  belong  to  the  decidua  and  chorion,  and  are 
parts  of  an  ovum  of  the  first  weeks  of  pregnancy."  Eokitansky  V 
report  contains  this  passage:  ''The  develoi)ment  of  the  mucous 
membrane  is  in  excess  of  its  usual  menstrual  degree.  It  is  not, 
however,  connected  with  conception." 

Blood  casts  will  readily  be  recognized  by  the  microscope.  K'o 
elements  of  uterine  mucous  membrane  are  discovered. 

The  microscope,  too,  will  readily  show  the  nature  of  fiilse  mem- 
branous casts  of  the  uterine  body,  and  of  exfoliations  of  the  vagina 
due  to  what  Dr.  Tyler  Smith  has  styled  epithelial  vaginitis,  or  to 
contact  with  perchloride  or  persulphate  of  iron. 

Symptoms.^-y^'^ith  the  commencement  of  the  menstrual  flow  there 
are  steady  pains,  wl)ich  increase  as  this  progresses  until  they 
become  violent  and  expulsive  like  those  of  abortion.     In  a  patient 


•  Mandl,  loc.  cit.,  p.  415.  «  Mandl,  loc.  cit.,  p.  416. 


MEMBRANOUS    D YSMENOERHCK A.  597 

whom  I  have  seen  with  Dr.  Walser,  of  Stateii  Island,  they  are  so 
excessive  that  she  cannot  find  words  to  express  her  dread  of  their 
recurrence.  Under  these  the  os  gradually  dilates,  and  the  mem- 
brane is  forced  out  into  the  vagina.  Then  there  is  conniionly  a 
tendency  to  menorrhagia,  which,  however,  soon  disappears,  and  the 
patient  has  passed  through  the  attack.  For  some  time  after  it  has 
passed  off  there  are  symptoms  of  endometritis,  and  purulent  and 
sanguineo-purulent  discharges.  Sometimes,  according  to  Huchard 
and  Labadie-Lagrave,  who  have  written  an  excellent  article  upon 
this  subject  in  the  Archives  Generales  for  July,  1870,  membranous 
dysmenorrhoea  becomes  complicated  by  diphtheritic  endometritis, 
wdiich  is  engrafted  upon  an  attack  of  endometritis  set  up  by  the 
aftection  which  we  are  considering. 

Pain  occurring  wnth  the  commencement  of  menstruation  ends 
only  wnth  the  discharge  of  the  exfoliated  membrane.  This  mem- 
brane, as  has  been  already  mentioned,  is  pathognomonic  of  the 
kind  of  dysmenorrhoea  which  exists,  and  serves  to  differentiate  it 
clearly  from  all  other  varieties.  The  appearance  of  the  membrane 
is  represented  in  Fig.  167. 

Fig.  167. 


Dysmenorrhoeal  membrane.     (Coste.) 

Prognosis. — The  prognosis  as  to  cure  is  extremely  unfavorable, 
although  cases,  not  only  of  complete  cure,  but  instances  in  which 
in  advanced  stages  of  the  disease  conception  has  occurred,  have 
been  reported  by  Siebold,^  Tyler  Smith,  D'Outrepont,  and  others. 

'  Mandl,  loc.  cit.,  p.  423. 


598  DYSMENOERHCEA. 

Treatment — When  the  etiology  and  pathogenesis  of  a  disease 
•  are  unknown,  it  is  astonishing  to  see  how  various,  contradictory, 
and  energetic,  treatment  usually  is.  Deficiency  of  knowledge  in 
these  respects  rarely  results  in  an  ex^Dectant  plan  of  treatment.  It 
commonly  induces  excessive  vigor  of  interference.  In  the  disease 
which  we  are  now  considering,  the  actual  cautery  has  been  freely 
applied  to  the  cervix,  while  solid  nitrate  of  silver  and  other  caustics 
have  been  carried  up  to  the  fundus. 

Uncertain  as  we  are  as  to  the  pathology  of  the  disorder,  little 
can  be  said  with  any  positiveness  as  to  treatment.  For  relief  of 
the  violent  pains  which  attend  the  attack,  nothing  compares  in 
quickness,  certainty,  and  efiiciency,  with  the  injection  of  morphia 
by  the  hypodermic  syringe.  If  this  use  of  the  drug  be  not  inad- 
missible on  account  of  constitutional  intolerance,  it  should  be 
resorted  to  once  in  every  eight  or  every  twelve  hours.  Should 
there  be  any  ol)jection  to  its  use,  the  pains  of  the  attack  should  be 
quieted  by  inhalations  of  sulphuric  ether  carried  only  to  the  point 
of  producing  quiescence  of  the  nervous  system,  not  sleep  or  uncon- 
sciousness. 

If  uterine  or  ovarian  disease  be  detected,  it  should  be  treated  in 
accordance  with  general  rules.  If  no  such  cause  for  the  exfoliation 
be  discovered,  applications  of  alterative  character  may  be  made  to 
the  uterine  mucous  membrane,  as  tincture  of  iodine,  chromic  or 
carbolic  acid,  solution  of  nitrate  of  silver,  or  solution  of  ]iersul])hate 
of  iron.  Should  displacement  exist,  it  should  be  relieved,  ujjou  the 
principle  that  if  we  cannot  cure  a  disorder,  it  is  at  least  wise  to 
relieve  its  most  prominent  complications  and  disagreeable  symp- 
toms. The  meagreness  of  this  advice  as  to  the  treatment  of  so  dis- 
tressing a  malady  is  but  too  apparent,  but  there  is  no  help  for  it,  as 
it  arises  from  an  absolute  want  of  knowledge  as  to  more  certain 
therapeutic  resources. 

In  treating  of  the  subject  of  dysmenorrhcea  I  have  accepted  all 
the  varieties  which  are  generally  indicated  by  authorities,  because 
I  believe  that  by  their  adoption  a  more  thorough  investigation  of 
the  subject  is  secured,  and  because  experience  leads  me  to  think 
that  a  recollection  of  them  at  the  bedside  will  aid  the  practitioner 
in  classification  and  treatment.  It  must  not,  however,  be  supposed 
that  every  case  of  dysmenorrhrea  will  prove  susceptible  of  strict 
limitation  to  one  of  these  varieties.  Such  an  anticipation  will  lead 
to  disappointment  and  distrust  of  this  classification.  Many,  indeed 
most,  cases  demonstrate  the  existence  of  more  than  one  disturbing 


MEMBRANOUS    D  YSMENORKHffi A.  599 

element.  Thus,  for  example,  retroversion  occurring  in  a  debilitated, 
weak,  and  nervous  woman,  whose  blood  is  impoverished,  might 
cause  a  dysmenorrhoea,  due  in  part  to  mechanical  obstruction,  in 
part  to  neuralgia,  in  part  to  congestion,  and,  perhaps,  even  to  a 
certain  extent  to  a  secondary  endometritis.  Too  much  must  not 
be  expected  from  any  classification,  and  it  must  be  borne  in  mind 
that  one  of  the  great  ends  in  view,  in  adopting  this  style  of 
arrangement,  is  the  attainment  of  thoroughness  of  investigation 
and  facility  of  remembrance. 

In  view  of  the  fact  which  I  have  just  mentioned,  it  is  well  for 
the  practitioner  to  have  at  his  disposal  some  general  plan  of  treat- 
ment which  may  be  resorted  to  in  cases  not  readily  susceptible  of 
classification.  The  following  is  one  which  I  think  will  be  found 
eftectual.  As  soon  as  menstruation  begins,  or  some  hours  before 
if  its  approach  can  be  recognized,  the  patient  should  go  to  bed 
and  apply  warmth,  by  bottles  of  warm  water,  warm  bricks  wrapped 
in  dry  flannel,  or,  as  is  better,  by  bags  of  India-rubber  filled  with 
Avarm  water,  to  the  feet,  abdomen,  and  sacrum  alternately.  She 
should  then  take  by  the  rectum  an  enema  composed  as  follows : 

R. — Tr.  assafcetidae,  .^iij. 

Tr.  belladonuae,  gtt.  xx. 
Tr.  opii,  gtt.  X. 
Aquae  tepidae,  ^iijss. — M. 
S. — Throw  the  whole  into  the  rectum  and  retain. 

If  the  patient  have  any  decided  objection  to  the  use  of  an  enema, 
the  following  prescription  will  be  found  very  useful : 

R. — Chloral  hydrat.  ^ij. 
Potassii  bromidi,  ^ij. 
Morphias  sulphat.  gr.  iss. 
Syrupi  aurantii  cort.  ^iij. — M. 
S. — A  dessertspoonful  in  a  wineglassful  oC  sweetened  water  every  four  hours  while 
in  pain. 

The  following  suppository  will  sometimes  prove  useful  in  plaea 
of  the  enema : 

R. — Belladonnae  ext.  gr.  j. 
Opii  pulv.  gr.  iij. 
AssafcEtidse  gum,  3ss. 
Butyr  cacao,  q.  s. 
M.  et  ft.  supposit.  No.  vi. 
S. — One  by  the  bowel  night  and  morning  while  suffering. 


600  DYSMENORRH(EA. 

Ovarian  Dysmenorrhoea. 

Definition. — In  a  number  of  cases,  unfortunately  by  no  means 
small,  no  depreciated  condition  of  the  nervous  system  will  be  found 
to  account  for  habitual  dysmenorrhea ;  and  the  most  careful  ex- 
ploration of  the  pelvis  will  fail  to  discover  uterine  or  periuterine 
disorder.  In  such  cases,  if  by  conjoined  maniiiulation  the  regions 
to  the  side  of  and  behind  the  uterus  be  investigated,  a  globular, 
slightly  compressible  mass,  about  the  size  of  a  large  walnut  or 
small  egg^  will  often  be  found  in  the  cul-de-sac  of  Douglas,  or  on  one 
or  both  sides  of  the  uterus,  low  down,  and  in  close  proximity  to  it. 
If  the  patient  be  now  placed  in  the  left  lateral  position,  and  two 
fingers  of  the  right  hand  be  carried  up  the  vagina,  their  palmar 
surfaces  looking  backwards,  the  presence  of  these  smooth  and 
movable  bodies  will  be  still  better  ascertained.  They  are  the 
ovaries,  enlarged,  congested,  tender,  and  prolapsed. 

In  some  cases  their  disordered  condition  will  be  accompaniec 
merely  by  dysmenorrhoea ;  but  in  others  it  will  be  marked  by 
hysteria,  amenorrhoea  alternating  with  menorrhagia,  and  even  by 
true  epilepsy.  Whether  epilepsy  is  in  such  cases  due  to  the  exist 
ing  ovarian  disease,  I  am,  of  course,  unprepared  to  state ;  but 
have  so  often  seen  it  accompany  it  that  I  freely  confess  my  beliefi 
that  it  is  sometimes  caused  by  it.  This  is  the  condition  commonly 
styled  chronic  ovaritis ;  which  consists  in  congestion  as  its  firstj 
stage,  and  hyperplasia  of  tissue  with  excessive  nervous  hyperresthe- 
sia  as  its  second. 

Symptoms. — It  would  be  difficult  to  make  the  diagnosis  of  thi^ 
form  of  painful  menstruation  by  rational  signs  alone.     It  shoulc 
rest  upon  a  union  of  rational  and  physical  signs;  but  a  suspicioi 
as  to  the  nature  of  the  case  would  generally  be  formed  from  the^ 
former.     The  pain  precedes  the  bloody  flow  l)y  several  days,  am 
diminishes  as  it  is  established.     It  is  of  a  dull  character,  extends] 
down  the  thighs,  is  peculiarly  likely  to  be  accompanied  by  nervoi 
manifestations,  and   to  create  depression  of  spirits.     The  breastslj 
often  sympathize,  becoming  painful  and  tender  to  the  touch. 

One  very  curious  phenomenon  which  now  and  then  marks  thesej 
cases  is  the  occurrence  of  intermenstrual,  or  "  intermediate  pain," 
as  it  has  been  styled  by  Dr.  Priestley.  At  times  this  occurs  with 
wonderful  regularity  on  a  given  day.  In  one  case  in  my  experience] 
it  occurred  on  the  ninth  day  after  menstruation  had  ceased;  inj 
another  on  the  fourteenth ;  and  in  a  third  it  commenced  one  week| 
after  the  menstrual  act,  and  continued  for  five  or  six  days. 


OVARIAN    DYSMENORRHCEA.  601 

It  must  not  be  supposed  that  in  every  case  in  v^^liich  tlie  ovaries 
are  discovered  to  be  large,  tender,  and  prolapsed,  dysmenorrhoea 
will  necessarily  exist ;  nor  that  they  will  always  be  found  in  this 
condition  where  there  are  other  reasons  for  suspecting  ovarian 
dysmenorrhoea.  The  rule  is  as  I  have  stated,  but  it  is  by  no  means 
without  exceptions. 

Pathology. — It  is  possible  that  the  process  of  ovulation  in  a  dis- 
eased ovary  may  excite,  through  its  extensive  and  decided  nervous 
connections,  congestion  and  nervous  hyperaesthesia  in  the  uterus, 
which  would  create  disordered  menstruation  of  the  congestive  or 
neuralgic  type.  Ordinarily,  however,  tlie  pain  seems  to  be  in  the  dis- 
eased ovaries  themselves,  and  to  depend  ujion  the  dehiscence  of  the 
follicles  of  De  Graaf.  This  can  be  proved  by  touching  these  organs 
during  the  early  periods  of  menstruation,  and  is  made  evident  in 
cases  in  which  ovulation  occurs  without  menstruation,  in  cases  of 
atresia  or  absence  of  the  uterus. 

Prognosis. — The  prognosis  of  dysmenorrhoea  due  to  this  cause  is 
very  bad.  In  a  young  girl  in  whom  ovarian  disorder  has  advanced 
only  to  congestion,  recovery  may  rapidly  take  place ;  but  in  a 
woman  further  advanced  in  life,  and  in  whom  chronic  enlargement 
of  the  ovaries  has  occurred,  and  become  associated  with  great  ten- 
derness and  prolapse,  the  prospects  of  cure  are  very  unpromising. 

Treatment. — In  such,  cases  sterility  is,  I  think,  the  rule.    If  utero- 

gestation  should  be  inaugurated,  the  nine  months  of  inactivity  and 

repose  secured  by  it  to  the  ovaries,  is  likely  to  effect  great  good. 

I  have  yet  to  meet  with  a  case  of  chronic  character  in  which  I 

I  have  efiected  a  cure  by  purely  medicinal  means.    By  anodynes  and 

'  nervines,  of  course  pain  may  be  annihilated,  but  this  is  far  from 

effecting  cure,  and  their  use  possesses  the  additional  disadvantage 

j  of  exposing  the  patient  to  the  dangers  of  contracting  a  bad  habit 

j  in  reference  to  their  future  use. 

I      All  means  calculated  to  soothe  local  irritation,  to  give  tone  to 

j  the  nervous  system,  and  to  combat  sanguineous  excitement,  should 

1  be  resorted  to.     Change  of  air  and  scene,  a  visit  to  the  mineral 

j  springs  and   baths  of  Germany  and  France,  and  removal  of  all 

I  influences  which  severely  or  disagreeably  tax  either  mind  or  body, 

will  often  accomplish  great  good.    "Warm  sitz  baths  and  warm  and 

soothing  vaginal  injections  should  be  employed,  and  complete  rest 

in  bed,  or  great  quietude  if  the  patient  objects  to  bed,  should  be 

prescril)ed  for  a  week  before  menstrual  periods  and  for  three  or  four 

I  lays  after  them.     Internally  I  know  of  no  means  which  are  so 

,  iflicacious  as  the  free  use  of  the  bromides  of  potassium  and  ammo- 


602  MENORRHAGIA    AND    METRORRHAGIA. 

Ilium,  commenced  a  week  before  the  menstrual  act  and  continued 
until  its  close. 

During  menstruation  opiates,  alcoholic  stimulants,  and  anaesthe- 
tics should,  as  far  as  possible,  be  avoided.  Their  use  will  probably 
give  relief,  and  as  a  consequence  they  will  be  resorted  to  once  a 
month  thereafter.  The  danger  of  such  a  couise  is  apparent.  In 
place  of  them  the  tincture  of  canabis  Indica,  hyoscyamus,  and 
camphor,  or  five  grain  doses  of  the  monobromate  of  camphor,  may 
be  employed.  In  some  cases  I  have  known  a  rectal  suppository 
of  five  grains  of  iodoform  give  great  relief. 

I  am  unwilling  to  convey  the  idea  that  even  these  means  are< 
prolific  of  good  results  in  such  cases.  They  are  by  no  means  so, 
and  are  merely  offered  as  the  best  with  which  I  am  acquainted. 
My  own  experience  leads  me  to  dread  the  application  for  relief  of 
one  of  these  obstinate  and  unsatisfactory  cases. 

i 

i 

■h 
CHAPTER    XXXYIII.  f 

MENORRHAGIA  AND  METRORRHAGIA. 

Definition. — The  first  of  these  terms  is  employed  for  the  design 
nation  of  a  profuse  and  excessive  flow  of  blood  at  the  menstrual 
periods;  the  second  for  any  flow  of  blood,  whether  profuse  or  not, 
during  the  intervals.  A  patient  who  menstruates  too  profusely  is 
said  to  suffer  from  menorrhagia,  while  one  who  loses  blood  not 
only  at  menstrual  periods  but  in  the  intervals  is  said  to  sufter  from 
metrorrhagia. 

•Frequency. — Both  of  these  conditions  are  necessarily  frequent, 
for  they  are  both  symptomatic  of  a  large  number  of  both  functional 
and  organic  aftections  of  the  uterus.  The  uterus  is  the  only  organ  in 
the  body  from  which  blood  flows  as  a  physiological  process.  Many 
organs  and  all  the  erectile  tissues  are  subject  to  normal  congestions, 
but  from  none  except  the  uterus  is  a  flow  of  blood  ever  other  than  i 
a  morbid  process.  It  is  not  then  astonishing  that  in  this  organ 
slight  and  numerous  causes  are  ai)t  to  excite  hemorrhage. 

Pathology. — Ist,  any  condition  which  induces  a  state  of  active  or 
passive  congestion  of  the  uterine  parenchyma  or  lining  membrane; 


CAUSES.  603 

2d,  any  iniluence  creating  a  solution  of  continuity  upon  its  mucous 
surface;  3d,  any  growth  which,  liaving  a  vascular  connection  with 
the  uterine  vessels,  allows  of  a  percolation  through  its  tissues  and 
from  its  circumference ;  and  4th,  any  agency  producing  dyscrasia 
of  the  blood  may  result  in  these  disorders.  Any  one  of  these  con- 
ditions existing  alone  may  produce  the  flow ;  several  combined  are 
still  more  certain  to  do  so.  It  must,  however,  be  admitted,  that 
very  violent  hemorrhages  will  sometimes  take  place  from  the  non- 
pregnant uterus  without  our  being  able  to  determine  their  cause, 
none  of  the  conditions  just  mentioned  being  recognizable. 

Causes. — The  conditions  which  most  frequently  occasion  menor- 
rhagia  and  metrorrhagia  are — 

General  plethora; 

Areolar  hyperplasia ; 

Polypus ; 

Fecal  impaction ; 

Granular  degeneration*, 

Fibrous  tumors ; 

Chronic  ovaritis ; 

Cancer  or  sarcoma; 

Retained  products  of  conception  ; 

Fungous  degeneration  of  uterine  mucous  membrane; 

Hematocele ; 

Subinvolution ; 

Any  displacement  of  the  uterus. 

Congestion  of  the  uterus  is  very  common  at  the  period  of  the 
menopause,  or  as  a  result  of  violent  muscular  efforts.  It  may  like- 
wise occur  as  a  consequence  of  abortion,  an  impeded  hepatic  circu- 
lation, endometritis,  areolar  hyperplasia,  displacements,  or  chronic 
ovaritis. 

Retention  of  some  of  the  products  of  conception  is  very  frequently 

I  cause.     The  placenta  may  remain  in  part  or  in  whole,  the  foetal 

^hell  may  become  a  mole,  or  the  chorion  may  undergo  degenera- 

1  ion,  and  uterine  hydatids,  as  they  are  erroneously  called,  collect 

A^ithin  the  uterus. 

That  simple  hyperplasia,  styled  vegetation  or  fungous  degenera- 
ion  of  the  lining  membrane  of  the  uterus,  is  not  an  infrequent 
•ource  of  both  varieties  of  hemorrhage.  The  vegetations  thus 
created  were  described  by  Recamier,  who  advised  and  practised 
craping  them  off  by  means  of  a  steel  instrument.     M.  Aran,  who 


604  MENORRHAGIA    AND    METRORRHAGIA. 

has  written  an  excellent  article  upon  them  in  his  work  on  the 
Diseases  of  the  Uterus,  thus  describes  them :  "  They  present  them- 
selves in  two  entirely  ditlerent  forms.  In  the  first  and  most 
common  form  they  are  tumors,  ordinarily  sessile,  continuous  with 
the  mucous  membrane  by  a  base  sometimes  as  large  as  themselves. 
They  vary  in  size  from  that  of  a  grain  of  wheat  or  a  little  pea  to 
that  of  a  large  jDea  and  even  of  a  small  strawberry  or  a  large  rasp- 
berry. The  last  are  often  pediculated."  These  are  styled  cellulo- 
vascular  vegetations,  and  may  exist  in  any  part  of  the  cavity  of  the 
uterus.  Generally  they  do  not  exceed  two  or  three  in  number,  and 
are  found  in  the  cavity  of  the  body.  "  In  the  second  form  they  are 
a  species  of  pediculated  vegetations  resembling  in  appearance  those 
follicular  polypi  which  are  so  common  in  the  neck  of  the  uterus. 
They  vary  in  size  from  that  of  a  grain  of  wheat  to  that  of  a  pea." 
These  are  called  cellulo-iibrous  vegetations.  Both  varieties  gene- 
rally result  from  chronic  engorgement  of  the  mucous  lining  of  the 
uterus.  As  a  consequence  of  subinvolution  tliey  are  very  fre- 
quently met  with,  and  markedly  complicate  that  condition. 

Sometimes  after  an  abortion,  at  other  times  after  labor  at  full 
term,  hemorrhage  will  steadily  continue  without  any  assignable 
cause.  If  the  cervical  canal  be  dilated  little  fungoid  growths  will 
be  found  attached  to  a  circumscribed  portion  of  the  uterine  wall, 
which  being  removed  by  the  curette,  the  flow  will  at  once  cease; 
This  variety  of  fungoid  growths  follows  so  closely  upon  the  partu- 
rient act,  that  it  appears  probable  that  they  arise  from  minute  por- 
tions of  placenta,  which,  remaining  attached,  draw  their  nourish- 
ment from  the  uterine  vessels.  I  have  no  positive  evidence  of  the 
truth  of  this  view,  for,  although  I  have  often  had  these  growths 
microscopically  examined,  I  have  not  obtained  it  in  this  wa 
Klob^  mentions  a  peculiar  kind  of  flat  vascular  elevation  which 
occurs  upon  the  mucous  membrane  of  the  uterus  which  I  have* 
never  seen.  "  These  puffed  elevations  are  red,  shiny,  velvety,  and 
smooth ;  on  scraping  them  with  a  knife  a  milky  fluid  exudea 
from  them,  which,  under  the  microscope,  exhibits  nothing  but  the 
glandular  epithelium  of  the  uterus,  sometimes  transparent  vesicles 
and  colloid  bodies  of  varying  size."  They  are  very  vascular.  Klob 
declares  that  in  the  case  of  a  women  36  years  of  age  death  occurred 
from  metrorrhagia.  He  examined  the  uterus  post  mortem,  and 
"  was  unable  to  find  anything  except  such  a  vegetation  of  mucous 

'  Op.  cit.,  p.  139. 


DIFFERENTIATION.  605 

membrane,  about  one  inch  thick  and  one  and  a  half  inches  in 
diameter." 

It  is  astonishing  how  profuse  and  constant  a  flow  will  sometimes 
result  from  very  small  and  apparently  insignificant  vegetations. 
Some  years  ago  I  had  an  opportunity  of  examining  post  mortem  a 
|uitient  of  Dr.  Louis  Elsberg,  of  this  city,  of  whom  this  history  was 
<;iven.  The  patient  had  suffered  for  years  from  menorrhagia  and 
occasionally  from  metrorrhagia.  On  many  occasions  Dr.  Elsberg 
liad  resorted  to  the  tampon,  and  on  several  had  been  forced  to  plug 
j  the  cervix  with  considerable  force  to  prevent  death  from  the  exces- 
i  sive  flow.  Upon  inspection  I  found  nothing  to  account  for  the 
condition  but  three  fungous  projections,  which  were  situated  just 
above  the  os  internum.  They  resembled  somewhat  tlie  warty 
growths  sometimes  seen  upon  the  glans  penis,  except  that  their 
papillary  character  was  not  so  marked.  Unfortunately  they  were 
destroyed  before  they  could  be  examined  by  the  microscope.  It 
may  be  suggested  that  some  other  cause  might  have  existed,  but 
none  such  was  discovered  upon  careful  investigation.  The  uterus, 
ovaries,  and  pelvic  tissues  appeared  to  be  in  a  perfectly  normal 
condition. 

Chronic  ovaritis  often  results  in  great  menstrual  irregularity, 
sometimes  for  months  the  menstrual  discharge  does  not  occur,  and 
then  without  any  apparent  exciting  cause  a  dangerously  profuse 
hemorrhage  occurs  which  requires  the  most  energetic  means  to  con- 
trol it. 

My  experience  furnishes  me  with  several  cases  in  which  fecal 
impaction  produced  prolonged  metrorrhagia  which  was  cured  by 
its  removal. 

Differentiation. — This  is  at  once  the  most  important  and  most 

(liliicult  of  the  physician's  duties  in  reference  to  the  symptoms 

wliich  we  are  considering.     If  he  be  too  easily  persuaded  to  look 

upon  the  loss  as  one  of  the  results  of  the  "change  of  life,"  or  even 

itf  primary  idiopathic  congestion,  much  time  may  be  lost  before 

his  error  is  corrected.     Should  he  forget  that  he  is  dealing  with  a 

■symptom,  and  look  upon  the  condition  as  a  disease,  he  will  often 

not  merely  lose  time,  but,  in  the  end,  entirely  fail  in  giving  relief; 

tor  the  empirical  practice  of  confining  such  patients  to  bed  and 

,  relying    upon    astringents,   cold    applications,  and   narcotics,  will 

ommonly  be  found  to  be  ineffectual.     In  every  case,  unless  the 

'ause  be  palpable,  it   is  advisable  to  examine  systematically  the 

ntire  uterus  and  its  surrounding  tissues  in  the  following  manner. 


606  MENORRHAGIA    AND    METRORRHAGIA. 

1st.  The  cervix  should  be  investigated  by  touch,  the  speculum, 
and  the  uterine  probe. 

2d.  The  anterior  and  posterior  Myalls,  and  the  fundus  and  sides 
of  the  uterus,  should  be  examined  by  conjoined  manipulation, 
palpation,  and  rectal  touch. 

3d.  The  whole  pelvis  should  be  explored  by  conjoined  manipula- 
tion, rectal  touch,  and  j)alpation. 

4th.  The  cervix  should  be  dilated  by  tents,  and  the  cavity  of  the 
body  explored  by  the  introduction  of  the  index  finger,  by  the 
uterine  sound,  and  the  curette. 

In  many  instances  a  diti gnosis  can  be  made  only  by  these  means; 
but  by  their  aid,  if  fully  developed,  very  few  cases  will  baffle 
research. 

Tents  offer  us  a  most  valuable  means  for  diagnosis  and  treat- 
ment, but  the  practitioner  must  be  very  sure  to  open  the  os  inter- 
num by  them  so  that  the  finger  may  pass  to  the  fundus.  In  many 
cases  when  it  is  supposed  that  a  full  investigation  of  the  uterine, 
cavity  has  been  made,  the  os  internum  has  never  been  passed  by. 
the  finger,  which  consequently  explores  only  the  cervical  canal.  Il 
will  not  infrequently  require  three  and  even  four  tents  to  open  th^ 
cavity  of  the  body  fully  to  the  finger. 

Prognosis. — This  will  depend  upon  the  cause  of  the  affection. 
Should  this  be  clearly  ascertainable  and  curable,  it  Avill,  of  course, 
differ  very  much  from  what  it  w^ould  be  if  the  cause  were  obscure 
and  ditficult  of  removal. 

Results, — Menorrhagia,  and  more  markedly  still,  metrorrhagia, 
if  unchecked,  may  result  in — 

Sterility ; 

Hydrsemia; 

Hysteria; 

Dyspepsia; 

Extreme  emaciation; 

Death.  i- 

Treatment- — This  is  palliative  and  curative.  The  treatment  of  ;| 
a  profuse  flow  of  blood  from  the  uterus,  as  from  any  other  part  off 
the  body,  should  always  consist  primarily  in  checking  it.  In  a| 
case  of  menorrhagia,  the  patient  should  be  kept  perfectly  quiet;|i 
upon  her  back;  cloths  wrung  out  of  cold  water  should  be  laicll 
over  the  uterus,  vulva,  and  thighs;  cold,  acidulated  drinks,  as  icedJi 
lemonade,  solution  of  elixir  of  vitriol  in  ice-water,  etc.,  should  be'| 
given  freely ;  and  the  ingestion  of  all  warm  fluids  strictly  inter-| 


TREATMENT.  607 

dieted.  Ill  addition,  the  apartment  should  be  kept  cool,  the  foot 
of  the  bedstead  elevated  about  ten  inches,  the  nervous  system 
quieted  by  opium,  or  an  appropriate  substitute,  and  all  conversation 
prohibited.  Certain  general  hemostatics  should  always  be  tried; 
aiiiono;  the  chief  of  which  are  gallic  acid,  ergot,  and  tincture  of 
cannabis  indica.     The  last  is  one  of  the  best  at  our  command. 

In  mild  cases  this  treatment  may  suffice,  but  in  severe  ones  it 
will  not.  In  these  the  speculum  should  be  introduced  and  the 
vagina  filled  with  a  tampon.  This  will  rarely  fail ;  but  in  certain 
eases,  as,  for  instance,  those  of  cancer  of  the  neck,  it  will  do  so. 
Tiider  these  circumstances  the  tampon  of  cotton  should  be  removed, 
and  replaced  by  one  consisting  of  the  same  material  saturated  with 
a  strong  solution  of  alum,  or  with  the  officinal  solution  of  persul- 
phate of  iron  diluted  with  four  times  its  bulk  of  water.  A 
stronger  solution  may  cause  sloughing  of  the  vaginal  mucous 
membrane.  A  solution  of  full  strength  has  been  known  to  produce 
iijangrene  of  the  vaginal  walls  themselves.  Instead  of  using  these 
s(^lutions  a  small  linen  bag  may  be  filled  with  powdered  alum, 
}ilaced  in  contact  with  the  cervix,  and  held  in  place  by  a  tampon ; 
i»r  two  drachms  of  tannin  may  be  left  free  against  the  part.  To 
these  means  almost  all  cases  will  yield  temporarily,  but  some  will 
be  met  with  which  will  not  do  so,  and  in  which  even  more  energetic 
ones  are  called  for  to  prevent  death  from  loss  of  blood.  In  these 
exceptional  cases  the  cavity  of  the  body  of  the  uterus  should  be 
freely  injected,  after  dilatation  of  the  cervical  canal,  with  the 
tincture  of  iodine,  or  solution  of  persulphate  of  iron,  one-third  to 
two  of  water. 

Before  a  case  of   menorrhagia  is  subjected  to   this  course  of 

management,  this  point  must  be  carefully  considered :  some  w^omen 

naturally  flow  very  freely  at  menstrual  epochs,  and  are  not  injured 

l»y  the  loss.     It  is  their  peculiarity,  and  not  an  evidence  of   an 

ibnorinal  state,  aind  it  should  be  decided  whether  or  not  treatment 

'^e  required.     In  reference  to  metrorrhagia,  it  is  equally  important 

0  bear  in  mind  that  some  women,  during  the  early  months  of 

iregnancy,  have  a  steady  flow  of  blood,  and  before  a  tent  is  em- 

tloyed,  or  probing  the  uterus  is  resorted  to,  this  state  should  be 

•arefully  eliminated. 

Curative  Treatment. — One  great  reason  for  the  fact  that  this  often 
iroves  fruitless  is  that  the  existing  disorder,  and  not  the  disease 
vhich  produces  it,  is  kept  before  the  mind  of  the  practitioner.  It 
liould  be  borne  in  mind  that  the  excessive  hemorrhage  is  usually  a 
ymptom,  and  that  the  disease  which  creates  it  must  be  sought  for 


608 


MENORRHAGIA  AND  METRORRHAGIA. 


and  eradicated.  I  believe  that  the  statement  already  made  that 
one  of  four  greac  pathological  factors  will  usually  be  found  to  hr- 
the  source  of  excessive  or  prolonged  uterine  hemorrhage,  will  stand 
the  test  of  experience  at  the  bedside.  I  therefore  place  before  the 
reader  at  a  glance  the  ordinary  causes  for  uterine  congestion,  solu- 
tion of  continuity,  growths  from  uterine  mucous  surface,  and  blood 
dyserasia.  That  tliere  are  other  conditions,  such  as  pelvic  peritoni- 
tis, hematocele,  etc.,  which  may  cause  uterine  hemorrhage,  I  do  not 
deny  ;  but  when  a  bloody  flow  marks  the  existence  of  such  grave 
diseases,  it  is  overshadowed  by  them  and  requires  no  S[iecial  treat- 
ment. I  here  give  those  which  oixlinarily  produce  a  flow  whicli 
requires  treatment  from  its  prominence  and  importance. 

Areolar  hyperplasia; 

Subinvolution; 

rn  .•         n    1.    •      .•  Fibroids; 

(jongestion  01  uterine  tissue  may       ,^  ,    ,    i 

.      ,    "  ^  (ieneral  plethora; 

JJisplacement; 

Fecal  impaction; 

Chronic  ovaritis. 
f  Ulceration; 
j  Granular  degeneration; 

Cancer ; 

Sarcoma. 

Polypi; 

Fungous  growths ; 

Adhering  products  of  concep- 
tion ; 

Fibroids ; 
^  Sarcoma  or  cancer. 
f  Scorbutus; 
I   Chlorosis ; 

J   Spanaemia    from     uremia    or 
I       other  grave   constitutional 
disease. 


Solution  of  continuity  may  be 
created  by 


Growths  from  uterine  walls  may 
consist  in 


Blood  dyserasia  may  be  due  to 


If  the  source  of  the  disorder  be  discovered,  its  treatment  is  often 
very  simple  and  eft'ectual,  and  as  the  management  of  most  of  the 
conditions  here  recorded  is  familiar  to  every  reader  upon  general 
medicine,  or  is  given  in  other  parts  of  this  work,  little  more  need 
be  said  except  upon  one  or  two  points. 

In  a  case  of  subinvolution,  the  free  use  of  ergot  will  be  found  a 
valuable  adjuvant  to  the  means  already  enumerated  for  palliative  :; 


TREATMENT.  609 

treatment,  and  it  may  prove  serviceable  as  a  curative  agent.  In 
the  treatment  of  all  uterine  congestions  the  occasional  use  of  an 
active  purgative,  or  the  systematic  and  steady  employment  of  the 
same  class  of  medicines  in  small  doses,  will  often  prove  highly 
beneficial. 

Tie<  it  merit  of  Fungous  Degeneration  of  the  Uterine  3Iw:ous  Mem- 
brane.— If  this  condition  be  clearly  diagnosticated,  not  surmised, 
1  )ut  fully  determined  upon  by  rational  and  physical  signs ;  tlie  first 
consisting  in  prolonged  hemorrhage,  without  the  existence  of  other 
disease;  and  the  second  in  evidence  afibrded  by  touch,  or  the  de- 
tachment or  expulsion  of  some  of  these  masses,  the  whole  lining 
membrane  of  the  uterine  body  should  be  thoroughly  but  gently 
scraped  by  the  curette  represented  in  Fig.  168. 

Fiff.  168. 


G.T/EMANN  &.C0. 

Curette  of  wire  without  cutting  edge. 

Should  the  cervical  canal  be  narrow,  it  may  be  necessary  to 
dilate  it  by  a  sea-tangle  tent ;  but,  ordinarily,  no  previous  dilatation 
is  necessary  for  the  use  of  this  instrument,  which  should  be  passed 
with  a  slight  degree  of  scraping  action  over  the  entire  surface  of 
the  uterine  body. 

In  recoramendino;  the  curette  as  a  most  valuable  resource  in  the 
treatment  of  menorrhagia  due  to  fungous  degeneration  of  the 
uterine  lining  membrane,  I  do  so  from  very  extensive  and  con- 
stantly increasing  experience  with  it.  I  employ  it  frequently  in 
private  practice,  and  in  the  Woman's  Hospital  it  is  commonly  used 
by  Dr.  Sims  and  myself.  N^ot  only  has  it  proved  in  my  hands,  as 
Dr.  Sims  informs  me  it  has  in  his,  a  very  efficient  instrument,  but 
one  attended  by  little  danger  unless  employed  in  cases  previously 
aftected  by  peritonitis  or  cellulitis.  For  one  using  it  with  such 
results  it  is  difiicult  to  comprehend  how  it  should  be  so  unfavora- 
bly regarded  by  many  able  practitioners.  The  late  M.  Aran^  was 
bitterly  opposed  to  a  resort  to  it ;  and  Gallard^  styles  its  use  a 
"detestable  operation."  The  latter  author  then  goes  on  to  speak 
of  the  "perfect^  harmlessness  of  intra-uterine  injections"  in  menor- 
rhagia !  Truly,  experience  does  not  teach  to  all  men  the  same 
lessons,  though  all  may  sincerely  strive  to  read  its  teachings  aright. 


Op.  cit..  p.  473.  2  Op.  cit.,  p.  242.  »  Op.  cit..  p.  254. 

39 


610  AMENORRHGEA. 

In  place  of  the  curette  the  lining  memhrane  of  the  uterine  body 
nvdy  be  modified  by  the  application  of  pure  nitric  acid,  after  thf 
plan  of  Kidd  and  Athill,  of  Dublin,  or  by  the  injection  of  the 
uterine  cavity  by  pure  tincture  of  iodine,  solution  of  nitrate  of 
silver,  or  solution  of  persulphate  of  iron  diluted  with  two  or  three 
equivalents  of  water.  As  a  full  discussion  as  to  the  dangers  of 
intra-uterine  injections  will  be  found  elsewhere,  I  shall  not  enter 
upon  it  here. 

Should  caustic  treatment  by  strong  acid  be  determined  upon, 
a  silver  or  vulcanite  tube  like  that  shown  in  Fig.  76  should  be 
passed  through  the  neck  to  protect  this  part,  and  preserve  the  acid 
for  energetic  action  on  the  lining  membrane  of  the  body. 

In  many  cases  replacement  and  support  of  a  displaced  uterus  will 
serve  to  relieve  a  prolonged  metrorrhagia,  while  the  same  results 
will  be  produced  in  others  by  cure  of  a  granular  and  bleeding 
cervix. 

All  disorder  of  the  blood  should  be  combated  by  appropriate  con- 
stitutional means,  even  where  it  is  secondary  to  the  loss,  and  not  a 
primary  cause  of  it.  Where  the  hemorrhage  is  due  to  a  polypus, 
the  resulting  blood  impoverishment  renders  escape  of  the  vital 
fluid  more  easy  and  rapid. 

In  very  obstinate  cases  a  change  from  a  warm  to  a  cold  climate, 
and  from  the  lowlands  to  a  mountainous  region,  often  accomplishes 
a  great  deal  of  good. 


CHAPTER   XXXIX. 

AMENORRHCEA. 

Definition. — Amenorrhoea,  a  term  derived  from  a,  privative,  a"?" 
"a  month,"  and  A^''^,  "I  flow,"  implies  an  absence  of  the  menstrual 
flow  in  a  woman  in  whom  it  should  naturally  exist.  Such  an 
absence  before  puberty,  after  the  menopause,  or  during  pregnancy 
and  lactation,  is  the  normal  condition,  and  hence  does  not  come 
within  the  definition. 

Freqvevry. — It  is  an  affection  of  great  frequency  among  women 
who  live  luxurious  and  indolent  lives,  and  disorder  the  nervous 


?.  I 


PATHOLOGY.  611 

and  sanguineous  systems  by  neglect  of  those  habits  which  keep 
them  in  a  state  of  liealtli.  Hence  it  is  very  frequently  encountered 
among  the  members  of  the  higher  classes  of  civilized  society  all 
over  the  world. 

Varieties. — If  the  habitual  monthly  discharge  be  suddenly  check- 
ed, the  disorder  is  styled  suppressio-mensium,  and  if  the  discharge 
have  never  appeared  in  a  woman  who  ought  to  menstruate 
regularly,  it  is  called  emansio-mensium. 

Pathology. — That  the  discharge  of  blood,  which  occurring  at 
monthly  periods  constitutes  menstruation,  is  a  true  hemorrhage 
dependent  upon  the  process  of  ovulation,  is  now  regarded  as  a 
settled  fact  by  most  physiologists.  In  accordance  with  a  law  of 
nature  which  we  recognize  in  its  effects  but  cannot  explain,  once 
in  every  twenty-eight  days  one  or  more  ovules  in  each  ovary  Imrst 
their  envelopes,  and  entering  the  Fallopian  tubes  pass  downwards 
to  the  uterus.  This  eruption  of  ovules  produces  in  the  ovaries  con- 
gestion and  nervous  exaltation,  which  continue  until  the  process  is 
completed. 

No  sooner  are  these  organs  thus  affected  than,  through  the  instru- 
mentality of  the  ganglionic  system  of  nerves  coimeeting  them  with 
the  uterus,  that  organ  sympathetically  undergoes  congestion  like- 
wise. The  whole  uterus  becomes  heavy  and  descends  perceptibly 
in  the  pelvis;  its  mucous  membrane  is  swollen  and  turgid,  and  the 
vessels  which  supply  it  dilate  under  an  excessive  hyper?emia,  as  do 
those  of  the  conjunctiva  in  conjunctivitis;  then  a  rupture  occurs 
and  relief  is  obtained  by  hemorrhage.  For  the  proper  perforniance 
of  the  function  three  elements  must  exist  in  a  jjerfect  state  of 
integrity:  1st,  the  uterus,  ovaries,  and  vagina  must  be  perfect  in 
form  and  vigor;  2d,  the  blood  must  be  in  its  normal  state;  and  3d, 
the  nervous  system  governing  the  relations  between  the  uterus  and 
ovaries  must  be  unimpaired  in  tone. 

Any  influence  disordering  one  or  more  of  these  may  check 
ovulation,  the  great  moving  cause  of  the  function;  prevent  the 
degree  of  sympathetic  congestion  necessary  for  rupture  of  uterine 
vessels ;  or  oppose  the  discharge  of  blood  which  has  been  effused. 

The  non-performance  of  the  function  of  menstruation  was 
formerly,  and  even  noAv  is  by  some,  regarded  as  productive  of  many 
constitutional  evils,  as,  for  example,  chlorosis,  phthisis,  dropsical 
effusions,  etc.  It  is  highly  probable  that  in  these  deductions  the 
effect  has  been  mistaken  for  the  cause.  The  impoverished  Idood, 
and  nervous  derangement  attendant  upon  these  affections,  result  in 
failure  of  that  function.     No  proof  exists  which  can  substantiate 


612  AMENOKRHCEA. 

the  view  that  amenorrhoea  ever  induces  permanent  lesion  of  any 
organ  in  the  body. 

Causes. — After  what  has  been  already  stated,  the  causes  of  the 
affection  may  be  tabulated  without  fear  of  confusing  the  reader. 

Amenorrhoea  may  result  from  any  of  the  following  conditions: 

Abnormal  states  of  organs  of  generation. 
Absence  of  uterus  or  ovaries; 
Rudimentary  uterus  or  ovaries; 
Occlusion  of  uterus  or  vagina; 
Uterine  atrophy; 
Pelvic  peritonitis; 
Atrophy  of  both  ovaries; 
Cystic  degeneration  of  both  ovaries. 

Abnormal  states  of  the  blood. 
Chlorosis ; 
Plethora ; 
Blood  state  of  phthisis; 

"         "     of  cirrhosis; 

"         "     of  Bright's  disease,  etc. 

Abnormal  state  of  ganglionic  nervous  system. 
Atony  from  mental  depression ; 
*'  "      indolence  arid  luxury ; 

"  "      want  of  fresh  air  and  exercise ; 

"  "      constitutional  diseases,  as  phthisis,  etc. 

Complete  absence  of  the  internal  organs  of  generation  is  very 
infrequent,  though  a  rudimentary  condition  is  less  rare.  With 
reference  to  absence  of  the  uterus,  Scanzoni  remarks :  "  On  carefully 
analyzing  the  reported  cases  of  entire  absence  of  the  womb,  we 
find  that  almost  always  some  rudiments  of  this  organ  still  exist,  so 
that  authenticated  and  unquestionable  instances  of  this  anomaly 
are  extremely  rare."  He  further  declares  that  he  has  never  been 
able  to  authenticate  a  single  case.  I  have  seen  one  instance  pre- 
sented by  Prof.  I.  E.  Taylor  to  the  Obstetrical  Society  of  this  city, 
in  which  no  trace  of  the  uterus  could  be  detected  upon  the  closest 
scrutiny  of  the  parts  removed  post  mortem. 

Absence  of  both  ovaries  is  quite  rare.  They  are  more  frequently 
found  to  be  in  a  rudimentary  condition  resembling  their  foetal  state. 

The  vagina  rnay  be  occluded  by  an  obturator  hymen,  contraction 
from  inflammation  and  sloughing,  or  from  congenital  or  acquired 
atresia. 


DIFFERENTIATION.  613 

So  likewise  may  the  canal  of  the  cervix  uteri  be  congenitally  or 
accidentally  closed. 

What  I  have  styled  atony  of  the  nervous  system,  has  been  well 
described  by  Prof.  Hodge,  of  Philadelphia,  under  the  name  of 
sedation.  It  consists  in  a  decrease  of  the  excitability,  vigor,  and 
activity  of  the  nervous  agency  which  controls  the  functions  of 
diftercnt  organs,  and  has  for  its  cause  physical  and  moral  influences, 
some  of  which  have  been  enumerated.  Some  of  the  functions 
which  are  under  the  control  of  the  ganglionic  system,  are  the  action 
of  the  heart,  digestion,  peristalsis,  and  regulation  of  animal  heat. 
In  one  leading  a  natural  and  healthy  life,  in  the  country  for 
example,  all  these  are  likely  to  be  normally  performed  ;  but  if  the 
same  individual  remove  to  a  crowded  city,  lead  the  life  of  a  student, 
exhaust  his  nerve  power  by  late  hours,  bad  air,  and  mental  etforts, 
all  of  them  rapidly  become  deranged.  He  suffers  from  palpitation 
of  the  heart,  dyspepsia,  coldness  of  hands  and  feet,  and  constipation. 
This  change  usually  occurs  slowly,  but  sometimes  it  does  so  rapidly, 
as  from  a  sea  voyage  or  any  very  violent  mental  strain.  In  a 
similar  manner  the  processes  of  ovulation  and  m^enstruation  are 
afiected  by  it,  in  some  cases  gradually,  in  others  with  great  rapidity. 

Differentiation. — Before  treatment  is  instituted  for  this  condition, 
it  must  be  carefully  differentiated  from — 

Pregnancy ; 
The  menopause; 
Tardy  menstruation. 

The  first  will  be  readily  recognized  by  its  characteristic  signs, 
if  suspicion  be  awakened,  and  they  be  investigated.  Very  often 
no  such  suspicion  arising,  the  criminal  desires  of  some  women  are 
gratified,  and  the  hopes  of  others  blighted  through  the  uninten- 
tional induction  of  abortion  by  the  treatment  adopted. 

The  law  with  regard  to  the  menopause  is,  that  it  should  occur 
between  the  ages  of  forty  and  fifty,  but  it  is  sometimes  delayed 
until  sixty  or  seventy,  and  at  others  takes  place  at  a  very  early  age. 
It  may  occur  as  early  as  the  twenty-first  year,  and  in  twenty-seven 
out  of  forty-nine  cases  of  early  cessation  collected  by  Dr.  Tilt,^  it 
took  place  from  the  twenty-seventh  to  the  thirty-ninth  year.  The 
absence  of  sensations  of  discomfort  at  the  periods  when  the  menses 
should  occur,  will  help  to  lead  the  practitioner  to  a  correct  conclu- 
sion as  to  the  character  of  the  case. 

'  On  Uterine  and  Ovarian  Inflammation,  p.  54. 


614  AMENOERHCEA. 

Sometimes  mothers  will  be  much  alarmed  by  absence  of  the 
function  in  girls  of  seventeen  and  eighteen  years.  It  should  be 
remembered  that  it  is  not  very  rare  for  it  to  be  delayed  until  those 
ages.  Differentiation  should  be  accomplished  under  these  circum- 
stances as  under  the  last  mentioned. 

Treatment. — From  what  has  been  already  said,  it  is  manifest  that 
amenorrhoea  is  not  a  disease,  but  a  symptom  of  some  local  or 
general  disorder,  and  it  follows  that  all  efforts  directed  simply  to 
re-establishment  of  the  absent  function,  must  necessarily  be  em})!- 
rical.  The  cause  should  be  discovered,  and,  if  possible,  removed. 
Should  it  be  susceptible  of  removal,  the  method  appropriate  for 
accomplishing  this  will  be  evident,  while  if  it  depend  upon  an 
incurable  condition,  great  benefit  will  be  gained  by  the  avoidance 
of  means  previously  practised  in  the  vain  hope  of  establishing  the 
flow,  and  by  our  ability  to  place  the  mind  of  the  patient  beyond 
the  harassing  influence  of  suspense. 

If  the  uterus  be  found  to  be  absent,  all  that  can  be  done  will  be 
to  abstract  a  sufl[icient  amount  of  blood  from  the  arm  by  venesection, 
if  necessary,  to  relieve  the  urgent  symptoms  attending  each  epoch. 

Occlusion  of  the  vagina  or  cervix  should  be  treated  by  surgical 
means,  the  barrier  being  overcome  by  the  knife,  scissors,  or  trocar. 

In  case  a  rudimentary  or  atrophied  uterus  be  discovered  as  the 
source  of  the  aftection,  it  should  be  developed  by  local  stimulation 
and  distention.  Once  every  week  or  every  two  weeks  it  should 
be  fully  distended  by  a  tent,  in  order  that  an  increase  of  nutrition 
and  consequent  increase  of  volume  and  capacity  may  be  excited. 
When  this  plan  is  not  in  operation,  an  intra-uterine  galvanic  pes- 
sary may  be  kept  in  utero  for  the  furtherance  of  the  same  end. 
It  is  astonishing  how  much  development  may  be  obtained  by  a  per- 
severing practice  of  this  plan.  In  many  instances  it  will  restore 
the  uterus  to  its  original  size,  and  cause  a  return  of  the  menstrual 
flow.  But  it  often  requires  considerable  time  to  bring  about  so 
favorable  a  result ;  even  years  may  elapse  before  it  is  fully  attained. 

If  it  be  decided  that  the  non-performance  of  the  function  is  due 
to  plethora,  anaemia,  or  chlorosis,  these  states  should  be  treated ; 
the  first  by  venesection,  strict  diet,  exercise,  and  a  life  in  the  open 
air;  the  second  and  third  by  change  of  air,  rich  food,  exercise,  and 
ferruginous  tonics.  In  plethora,  Prof.  Bedford  speaks  highly  of 
the  abstraction  of  blood  from  the  arm  at  intervals  of  a  month,  the 
abstraction  being  performed  between  the  menstrual  epochs. 

Should  some  grave  constitutional  condition  like  tuberculosis  or 


TREATMENT.  615 

the  others  mentioned,  be  found  to  be  the  main  morbid  state,  it,  and 
not  its  resulting  symptom,  sliould  attract  attention. 

An  atonic  state  of  the  nervous  system  governing  menstruation 
should  be  treated  by  a  resort  to  a  general  tonic  course.  Among 
the  means  applicable  to  its  removal  may  be  es];ecially  mentioned, 
oxercise  on  foot  and  horseback,  rowing,  calisthenics,  sea-bathing, 
nutritious  food,  and  nervous  tonics  of  medical  character,  as  nux 
vomica,  strychnine,  quinine,  and  the  general  use  of  electricity.  It 
is  in  this  class  of  cases  that  many  drugs  and  prescriptions  styled 
emmenagogue  have  often  succeeded  in  restoring  the  function  even 
when  used  empirically.  A  state  of  general  nervous  atony  is 
frequently  attended  by  chlorosis  and  always  by  constipation.  The 
nervous  disorder  and  two  of  its  resulting  symptoms  may  be  favor- 
ably affected  by  the  stereotyped  combination  of  aloes,  iron,  arid 
myrrh  or  nux  vomica ;  and  the  sluggish  nerve  power  may  be  tem- 
porarily excited  to  the  performance  of  its  duties  by  the  administra- 
tion of  tansy,  rue,  ergot,  or  savine.  But  it  is  not  through  desultory 
means  of  this  character  that  a  cure  can  be  anticipated  Avith  any 
confidence.  A  more  comprehensive  plan  directed  to  the  improve- 
ment of  the  patient's  constitution  should  be  adopted  and  systema- 
tically pursued.  As  general  means  those  already  mentioned  will 
always  be  found  highly  useful.  If  the  patient  while  at  home  cannot 
l)e  prevailed  upon  to  practise  sutiicient  self-denial  to  avoid  what  is 
injurious,  or  be  made  to  develop  the  energy  necessary  to  follow  a 
course  which  requires  effort,  she  may,  with  great  advantage,  be 
])iaced  for  a  time  in  a  well-regulated  hydropathic  establishment, 
where  the  early  hours  of  retiring,  simple  food,  exercise,  society, 
l)ure  air,  and  bathing,  will  accomplish  a  roborant  effect  which  will 
}>rove  of  great  value  in  the  cure  of  the  affection. 

But  not  merely  should  constitutional  means  be  adopted.  After 
the  general  condition  has  been  improved,  local  stimuli  may  be 
resorted  to  with  great  benefit.  Those  which  will  be  found  to  be 
most  efiicient  are — 

Passage  of  the  sound; 
Tents ; 
Cupping ; 
Electricity; 
Stimulating  enemata; 
Baths. 

In  their  action  these  means  probably  exert  an  influence  not  only 
on  the  uterus,  but  sometimes  by  their  stimulating  effects  excite 


616  AMENOEEHCEA. 

the  process  of  ovulation.  The  sound  should  be  passed  up  to  the 
fundus  once  every  day  for  three  or  four  days  before  the  expected 
flow,  or  if  the  process  of  ovulation  do  not  demonstrate  its  exist- 
ence, it  may  be  passed  once  a  week  throughout  the  month.  At 
the  same  periods  tents  of  sponge  or  sea-tangle  may  be  used,  the 
dano-ers  attending  them  being  always  borne  in  mind  during  their 
employment. 

The  cervix  uteri  may,  by  the  application  of  an  exhauster  or  dry 
cup,  have  a  marked  hypersemia  excited  within  it,  which  extends 
to  the  uterine  body  and  replaces  that  which  should  have  occurred 
from  physiological  causes.  A  very  simple  method  for  producing 
it  is  to  enclose  the  cervix  Avithin  the  mouth  of  the  cylinder  of  hard 
rubber  represented  in  Fig.  169,  and  then  exhaust  the  air  by  with- 
drawing the  piston. 

Fiff.  1G9. 


Syringe  for  dry  cupping  the  cervix. 

Before  the  introduction  of  this  instrument  the  uterus  should  be 
exposed  by  means  of  the  speculum.  In  this  way  I  have  repeatedly 
drawn,  without  effort,  one  or  two  drachms  of  blood  tlu'ough  the 
mucous  lining  of  the  neck. 

Electricity  is  a  means  of  some  value.  One  pole  of  a  battery 
may  be  applied  over  the  lower  portion  of  the  spine  and  the  other 
passed  over  the  hypogastrium,  placed  in  contact  with  the  cervix, 
or  even  carried,  by  means  of  a  wire  covered,  except  for  its  terminal 
three  inches,  with  a  gum-elastic  catheter,  up  to  the  fundus  of  the 
uterus.  For  the  purpose  of  keeping  up  a  mild  but  steady  current 
within  the  uterus,  Prof.  Simpson  has  advised  a  stem  composed  of 
copper  for  one-half  its  length  and  zinc  for  the  other  half,  which  is 
passed  up  to  the  fundus.  It  has  an  ovoid  disk  at  its  lower  extremity 
upon  wliich  the  cervix  rests.  Dr.  Noeggerath  has  made  an  im- 
provement in  this  by  having  the  stem  composed  of  two  parallel 
pieces  of  copper  and  zinc,  instead  of  two  short  pieces  of  these 
metals  united  at  the  centre  of  the  stem.  As  these  instruments 
must  be  left  in  place  while  the  patient  walks  about,  there  is 
always  danger  of  their  irritating  the  walls  of  the  uterus  to  too 
great  an  extent.  To  avoid  this  I  liave  employed  a  stem  composed 
of  alternate  beads  of  copper  and  zinc,  held  together  by  a  small  wire 
rope,  which  passes  through  the  centre  of  each,  and  is  secured  to 


TREATMENT. 


617 


the  uppermost  and  to  the  vaginal  disk  below.     This  may,  by  any 
movement  of  the  uterus,  be  bent  at  the  required  angle,  and  conse- 
quently can  do  no  injury.     (Fig.  170.)     The  disk 
or  bulb  of  this    instrument  should  be  made  glo-  Fig-  1"0. 

bular  so  as  to  rest  in  the  cup  held  between  the 
branches  of  a  Hodge  or  Smith  pessary,  as  shown 
in  Fig.  130. 

As  an  excitant  of  the  menstrual  flow,  enemata 
of  very  warm  water  impregnated  with  chloride  of 
sodium,  aloes,  or  soap,  constitute  a  valuable  re-  Galvanic  pessary 
source.  E^ot  only  does  the  medicinal  substance 
irritate  the  uterine  nerves,  the  warm  fluid  brought  into  close  con- 
tact with  the  uterus  also  excites  a  flow  of  blood  to  it.  Hip-baths 
and  pediluvia  have  long  been  resorted  to  for  the  purpose  of  exciting 
menstruation.  They  should  be  prolonged,  and  as  warm  as  the 
patient  can  bear  them.  In  addition  to  these  means,  copious  injec- 
tions of  warm  water  may  with  benefit  be  thrown  into  the  vagina. 
one  or  even  two  gallons  being,  by  means  of  a  proper  syringe,  pro- 
jected against  the  os  uteri. 

Reasoning  from  analogy  and  from  our  knowledge  of  the  physi- 
ology of  menstruation,  we  are  unquestionably  M'arranted  in  the 
deduction  that  in  a  certain  number  of  cases  amenorrhoea  is  due  to 
non-performance  of 'the  function  of  ovulation.  It  is  not  possible 
to  give  clinical  evidence  of  the  fact,  but  it  may  be  strongly  sur- 
mised, when  none  of  the  symptoms  usually  attendant  upon  this  pro- 
cess present  themselves  at  monthly  periods.  The  means  by  which 
it  should  be  treated  are  those  already  advised,  for  any  of  the  causes  ' 
mentioned  may  produce  that  variety  of  the  affection  which  is  due 
to  non-performance  of  ovarian  functions,  in  the  same  manner  that 
they  give  rise  to  that  form  depending  upon  the  incapacity  of  the 
uterus. 


618  LEUCORRHCEA. 


CHAPTER    XL. 

LEUCORRHCEA. 

In  my  anxiety  to  impress  tlie  importance  of  regarding  and  treat- 
ing this  condition  as  a  symptom  of  uterine  or  vaginal  disease,  and 
not  as  a  primary  affection,  I  have  been  in  great  doubt  as  to  the 
propriety  of  devoting  a  separate  chapter  to  it.  In  doing  so,  I  con- 
fess that  I  yield  to  a  conventional  practice  which  I  do  not  fully 
endorse,  and  I  offer  this  fact  as  an  explanation  of  any  superficiality 
in  the  treatment  of  the  subject  which  may  strike  the  reader.  I 
feel  very  sure  that  the  writer  of  fifty  years  hence  will  omit  the 
separate  consideration  of  this  symptom  entirely. 

Definiiion. — This  affection,  the  name  of  which  is  derived  from 
Xfvxo?,  "  white,"  and  /Jtto,  "  I  flow,"  consists  in  a  whitish,  yellowisli, 
or  greenish  mucous  discharge  from  the  vagina. 

Synonyms. — It  has  been,  in  modern  times,  described  under  the 
names  of  fluor  albus,  blennorrhoea,  pertes  blanches,  fleurs  blanches, 
and  whites.  In  ancient  literature  the  variety  of  names  which  was 
applied  to  it  may  be  judged  of  when  it  is  stated  that  over  fifty 
appellations  were  at  different  times  employed  in  designating  it. 

Frequenry. — No  disease  or  symptom  in  the  whole  list  of  female 
ills  is  so  common.  Probably  no  woman  ever  goes  through  life 
without  at  some  period,  and  for  a  variable  time,  suffering  from  it. 
It  is  only  when  it  becomes  annoying  by  its  constancy,  abundance, 
or  irritating  properties,  that  it  attracts  attention  and  causes  the 
patient  to  seek  assistance. 

History. — In  the  earliest  writings  of  the  Greek  school  and 
throughout  Roman  and  Arabian  medical  literature,  abundant  de- 
scriptions of  this  disorder  may  be  found.  Hippocrates  described 
it,  pointing  out  as  among  its  symptoms,  puffiness  of  tlie  face,  pale- 
ness, and  enlargement  of  the  abdomen.  He  evinces  a  familiarity 
with  its  treatment  by  an  admission  of  the  difficulty  of  curing  it. 
AretiBUS  of  Cappadocia,  in  the  first  century,  mentioned  the  varie- 
ties of  leucorrhoea,  as  to  color,  quantity,  etc.,  and  Aetius  and  Paul 
of  ^gina  speak  of  two  forms  of  the  affection,  red  and  white  flux. 
For  the  latter,  Aetius  reconnnends  gestation,  vociferation,  walk- 


PATHOLOGY.  619 

ing,  etc.  The  Arabians,  Haly  Abbas,  and  Alsaharavius,  wrote 
upon  tlie  subject,  but  advanced  nothing  new. 

As  in  ancient  times,  so  also  in  modern,  it  has  attracted  a  great 
deal  of  attention,  and  until  the  establishment  of  the  present  school 
of  gynecology  by  Recamier,  was  treated  of  as  a  disease  rather 
than  as  a  vsymptom.  Even  long  after  this  period  it  was  commonly 
regarded  as  a  disease ;  the  result  of  constitutional  debility,  or  the 
index  of  an  impure  blood  state.  For  the  views  which  are  now 
entertained  concerning  it,  we  are  indebted  to  no  one  so  much  as 
to  Dr.  J.  II.  Bennet,  of  London,  who,  by  his  forcible  reasonings 
supported  by  clinical  evidence,  clearly  demonstrated  its  ordinary 
dependence  as  a  symptom  upon  some  local  lesion.  Dr.  Tyler 
Smith,  in  an  elaborate  essay  upon  the  subject,  has  also  done  much 
to  elucidate  certain  points  in  its  pathology,  which  before  his  time 
had  been  undeveloped. 

Pathology. — -As  a  discharge  of  mucus  or  muco-pus  is  a  symp- 
tom of  urethritis,  bronchitis,  nasal  catarrh,  and  faucitis,  so  is  it  a 
symptom  of  inflammation  of  the  vagina  and  lining  membrane  of 
the  uterus  and  Fallopian  tubes.  Whatever  influence  is  capable  of 
creating  it  elsewhere  maj^  give  rise  to  it  here,  and  in  this  position 
it  is,  as  it  is  elsewhere,  only  an  isolated  sign  of  a  pathological  state. 
It  is  not  by  any  means,  however,  always  an  evidence  of  inflamma- 
tory action.  As  many  individuals  upon  exposure  to  cold  will  freely 
(discharge  mucus  from  the  nostrils  without  any  inflammation  exist- 
ing, so  will  many  women  sufier  from  leucorrhoea  from  any  cause 
producing  a  temporary  congestion  of  the  mucous  membrane.  But 
in  these  cases  the  disease  is  temporary,  following  or  preceding  the 
menstrual  congestion,  or  arising  from  fatigue  or  exhaustion. 
When  it  becomes  permanent  and  the  discharge  grows  profuse  or 
acrid,  its  connection  with  a  morbid  state  is  rendered  probable. 
lAt  such  times  it  is  always  a  symptom  of  some  abnormal  condition 
lof  the  uterus.  Fallopian  tubes,  or  vagina,  and  its  presence  should 
iead  to  an  investigation  of  these  organs. 

Any  agency  which  moderately  increases  vascular  activity  in  a 
secreting  organ,  tends  to  augment  the  amount  of  its  secretion.  I 
3ay  moderately  increases,  because  an  excessive  turgescence,  such 
18  attends  upon  acute  inflammation,  checks  secretion  entirely, 
uch  an  influence  being  exerted  upon  any  part  of  the  mucous 
covering  of  the  generative  canal  of  the  female,  an  excessive  flow 
)f  plasma,  together  with  a  rapid  exfoliation  of  epithelial  cells  and 
he  formation  of  pus-corpuscles,  results. 


620 


LEUCORRHCEA. 


Varieties. — Leucorrhoea  is  divided  into  two  varieties,  according 
to  its  origin — vaginal  and  uterine.  Eitlier  of  tliese  may  exist 
separately,  or  the  two  may  coexist.  If  it  be  vaginal,  it  may  con- 
tinue as  such  for  a  length  of  time,  or  pass  upwards  into  the  uterus 
and  tubes.  If  the  inflammatory  action  producing  the  discharge 
be  confined  to  the  uterine  mucous  membrane,  it  may  remain  so 
without  implicating  the  vagina,  but  that  canal  receiving  the 
products  of  uterine  secretion  is  generally  excited  into  morbid  ac- 
tion. A  similar  result  may  frequently  be  observed  in  nasal  catarrh 
in  children,  the  upper  lip  being  bereft  of  its  epithelial  investment, 
and  a  papular  or  vesicular  eruption  excited  over  the  neighboring 
parts  of  the  face. 

Vaginal  leucorrhoea  consists  of  a  white,  creamy,  purulent-look- 
ing fluid,  which  is  composed,  according  to  Dr.  Tyler  Smith,  of  the 
following  elements : 

Acid  plasma ; 
Scaly  epithelium ; 
Pus-corpuscles ; 
Blood-globules ; 
Fatty  matter. 

Under  the  microscope  it  appears  as  represented  in  Fig.  171. 


Fig.  171. 


Vaginal  leucorrhcea  under  the  microscope.     (Smith.) 

That  arising  from  the  canal  of  the  cervix  is  thick,  tenacious, 
ropy,  like  the  white  of  egg,  and  consists  of— 

Alkaline  plasma ; 
^lucous  corpuscles ; 


f  i 

^  I 


and 


CAUSES. 


621 


Altered  cylindrical  ejDithelium ; 
Pus-corpuscles ; 
Blood-globules ; 
Fatty  particles. 

Examined  by  the  microscope  it  presents  the  appearance  shown 
in  Fig.  172. 


Fig.  172. 


-^-. 


.^^S;^^js&-ii 


■-UV,    Vi^t 


Cervical  lencorrhcea  under  the  microscope.     (Smith.) 


That  arising  from  the  body  of  the  uterus  resembles  the  cervical 
form,  except  that  it  is  less  gelatinous,  less  ropy,  and  more  likely 
to  be  tinged  with  blood. 

Causes. — It  has  been  customary  to  treat  of  the  causes  of  this 
atfeotion  under  two  heads,  constitutional  and  local.  They  may  be 
more  correctly  appreciated  by  dividing  them  into  those  causes 
wliich  produce  it  by  creating  congestion,  and  those  causing  it  by 
inflammation. 

Causes  by  Congestion. 

Subinvolution  of  uterus  or  vagina; 

Suppressed  menstruation  ; 

Fibroids,  polypi,  or  fungous  vegetations  ; 

Prolonged  lactation ; 

Gestation  and  parturition; 

Excessive  coition; 

Anaemia ; 

Uterine  displacement. 

Causes  by  Inflammation. 

Endometritis,  corporeal  or  cervical ; 
Granular  degeneration; 


622  LEUCOEEHCEA. 

Syphilitic  ulceration ; 
Fibroids  or  polypi ; 
Vaginitis,  specific  or  simple. 

It  will  thus  be  seen  that  the  disorder  may  in  some  instances  be 
a  trivial  matter,  which,  by  a  judicious  combination  of  general  and 
local  means,  will  rapidly  disappear,  while  in  many  others  it  is 
an  attendant  circumstance  of  some  grave  pathological  state  of  the 
uterus  or  vagina,  and  consequently  difficult  of  cure. 

Prognosis. — This  will  dei)ond  in  great  degree  upon  the  cause. 
If  this  can  be  readily  removed,  the  prognosis  will  be  favorable; 
while  if  it  be  connected  with  some  serious  organic  lesion,  it  will 
not  be  so. 

Hesults. — Uterine  leucorrlioea  may  result  in — 

Sterility ; 
Vaginitis ; 
Pruritus  vulvae; 
Vulvitis ; 
Salpingitis ; 
Granular  degeneration. 

Dr.  Tyler  Smith,  in  the  work  just  referred  to,  declares  that  it  is 
even  the  cause  of  parenchymatous  disease.  It  is  much  more  pro- 
bable that  the  endometritis  which  results  in  the  discharge  also  pro- 
duces this  by  disordering  nutrition. 

Treatment. — When  a  patient  applies  to  a  practitioner  for  the  cure 
of  leucorrlioea,  it  should  be  his  first  endeavor  to  discover  the  cause 
of  the  muco-purulent  flow.  A  suspicion  as  to  the  source  of  the 
difficulty  may  ordinarily  be  based  ui>on  examination  into  the 
rational  signs,  but  a  diagnosis  of  the  condition  which  gives  rise  to 
the  symptom  which  has  excited  anxiet}^  in  the  mind  of  the  patient 
can  be  more  fully  ascertained  by  physical  exploration.  If  upon  this, 
disease  of  the  uterus,  vagina,  or  Fallopian  tubes  be  discovered  to 
exist,  either  in  the  form  of  inflammation  or  congestion,  this  aftec- . 
tion  should  receive  appropriate  treatment.  To  recapitulate  tlie 
plans  which  should  be  pursued  would  here  be  entirely  out  of  place, 
for  they  are  laid  down  in  other  parts  of  this  work  in  connection 
with  the  special  disorders  of  these  parts. 

A  course  especially  adapted  to  giving  tone  to  the  dilated  blood- 
vessels of  the  mucous  membrane,  and  overcoming  the  tendency  to 
excessive  creation  of  cells  and  exudation  of  blood  plasma,  should  in 
addition  be  adopted.     To  begin  with,  the  patient  should  be  put. 


TKEATMENT.  623 

upon  general  tonic  treatment,  such  as  the  use  of  quinine,  Peruvian 
bark,  strychnine,  and  iron;  sea-bathing;  change  of  air  and  scene; 
and  the  substitution  of  quiet  and  cheerful  social  intlueiices  for  those 
which  are  exciting  or  depressing.  The  diet  should  also  be  made 
nutritious  and  simple,  and  all  stimulants,  spices,  and  condiments  be 
strictly  avoided. 

In  the  way  of  local  treatment  the  vagina,  after  having  been  care- 
fully cleansed,  should,  by  means  of  a  sponge  probang,  be  thoroughly 
waslied  over  with  a  solution  of  the  nitrate  of  silver,  one  part  to 
i^ight  or  ten  of  water.  After  this  a  tampon  of  cotton  saturated 
with  glycerine  should  be  left  in  the  canal  for  twenty-four  hours 
and  removed  by  the  patient,  a  thread  being  attached  to  it  for  this 
})urpose.  Then  copious  astringent  and  soothing  vaginal  injections 
should  be  employed  night  and  morning.  The  best  astringents  for 
this  purpose  are  alum,  tannin,  infusion  of  oak  bark,  zinc,  and  lead. 
As  examples  of  good  combinations  I  give  the  following : 

R. — Acidi  taniiici,  5iv. 
Glycerin.'E,  5xvj. — M. 
S. — A  tablespoonful  to  a  quart  of  tepid  water,  to  be  used  as  a  vaginal  injection 
for  five  minutes  every  night  and  morning  by  means  of  Davidson's  or  the  fountain 
syringe. 

R. — Zinci  sulphat.  ^iss. 
Aluminis  sulphat.  ^iss. 
GlyceriniE,  3VJ. — M. 
Follow  same  directions  as  those  above  giveu. 

Once  a  week  the  application  of  the  solution  of  nitrate  of  silver, 
in  diminishing  strength,  should  be  repeated  and  followed  by  the 
use  of  the  tampon  of  cotton  soaked  in  glycerine,  or  glycerine  and 
tannin,  until  cure  is  effected.  Cure  will  commonly  be  effected  by 
these  means,  if  no  other  disorder  exist  to  reproduce  a  sj^mptom 
which  it  has  once  proved  itself  efficient  to  establish.  If  such  a 
condition  exist  and  be  overlooked  hy  the  practitioner,  it  will  in- 
evitably do  again  what  it  did  before.  Neither  plan  should  be  de- 
tpised — treatment  of  the  causative  disorder  nor  that  of  the  result- 
ng  symptom  ;  and  by  a  combination  of  the  two  plans  better  results 
vill  be  obtained  than  "coiild  be  accomplished  by  an  exclusive  ad- 
lerence  to  either. 

In  cases  of  chronic  vaginitis,  astringents  sometimes  appear  to  do 
larm,  and  infusions  of  flaxseed,  slippery  elm,  and  similar  substances 
ften  prove  beneficiaL  On  the  other  hand,  in  the  treatment  of 
hronic  endometritis,  it  will  often  be  found  of  benefit  to  use  as- 
ringent  injections  which  act  not  only  by  securing  cleanliness,  but 


024  STERILITY. 

by  hardening  the  vaginal  mucous  membrane  and  preventing  the 
complication  of  vaginitis.  To  enter  more  minutely  into  the  treat- 
ment of  leucorrhoea  would  be  to  defeat  the  main  object  which  I 
have  had  in  view,  that  of  subordinating  the  consideration  of  this 
disorder  to  that  of  the  diseased  states  which  produce  it. 


CHAPTER    XLI. 

STERILITY, 

Definition  and  Synonyms. — This  term,  which  is  derived  from 
5rfpf05,  "barren,"  and  implies  an  incapacity  for  conception,  is  synon- 
ymously entitled  barrenness  and  infecundity. 

History. — Throughout  medical  literature,  from  the  earliest  periods  • 
to  the  present,  it  has  attracted  special  attention,  and  been  the  sub- 
ject of  dissertations  by  all  authors  who  have  touched  upon  the 
aftectious  peculiar  to  females.     The  frequent  reference  made  to  it  i 
by  Biblical  writers  as  a  reproach  to  women,  is  too  well  known  to  • 
require  special  mention. 

Causes. — To  comprehend  the  pathology  of  sterility,  the  physi- 
ology of  conception  must  be  clearly  understood.  In  the  act  of 
coition  the  male  organ,  being  introduced  into  tlie  vagina,  projects  f 
into  and  against  the  cervix  a  fluid,  consisting  of  a  thick,  watery 
portion,  holding  in  suspension  large  numbers  of  ciliated  cells  which 
have  the  power  of  moving  by  ciliary  action.  The  bulk  of  this 
fluid  pours  down  into  the  vagina,  but  many  of  tlie  cells  which  it 
contains  pass  upwards  into  the  body  of  the  uterus,  and  through 
the  Fallopian  tubes  as  far  as  the  ovaries.  Should  they  come  in 
contact  with  an  ovule,  impregnation  may  take  place  in  the  ovaries. 
Fallopian  tubes,  or  uterus.  When  the  impregnated  ovule  attaches 
itself  to  the  uterus,  the  mucous  membrane  of  this  organ  undergoes 
exuberant  development,  and  throws  around  it  an  envelope  called  « 
the  decidua  reflexa.  Further  than  this,  the  process  does  not  concern  • 
us,  for  conception  has  then  followed  impregnation,  fixation  of  the 
impregnated  ovum  having  occurred. 

These  facts  being  kept  in  mind,  it  becomes  evident  that  a  variety 
of  influences  may  interfere  with  the  performance  of  this  delicate 


CAUSES.  625 

and  subtle  process.  For  its  accomplishment  four  things  are  neces- 
sary as  far  as  the  woman  is  concerned. 

1st.  The  possibility  of  the  entrance  of  seminal  fluid  into  the 
uterus ; 

2d.  The  possil)ility  of  the  production  of  a  healthy  ovule; 

3d.  The  possibility  of  the  entrance  of  an  ovule  into  the  uterus; 

4th.  The  absence  of  influences  in  utero  destructive  to  the  vitality 
of  the  semen,  and  preventive  of  fixation  of  the  ovum  upon  the 
uterine  wall. 

Should  these  four  conditions  exist,  no  woman  will  be  sterile. 
She  may  not  bear  children,  but  the  incapacity  may  attach  to  the 
male  and  not  to  her;  or  having  conceived,  she  may  have  suffered 
from  consecutive  abortions,  which  have  been  mistaken  for  attacks 
of  nienorrhao;ia. 

The  special  causes  of  sterility,  or  those  interfering  with  these 
conditions,  may  be  thus  presented: 

1st.  Causes  preveiUmg  entrance  of  semen  into  the  uterus. 

Absence  of  the  uterus  or  vagina ; 

Obturator  hymen; 

Vaginismus ; 

Atresia  vaginge; 

Occlusion  of  cervical  canal; 

Conical  shape  of  cervix; 

Cervical  endometritis ; 

Polypi  or  fibroids; 

Displacements ;  '' 

Very  small  os  internum. 
2d.  Causes  prevevting  the  pjroduction  of  a  healthy  ovule. 

Chronic  ovaritis; 

Cystic  disease  of  both  ovaries; 

Cellulitis  or  peritonitis; 

Absence  of  ovaries. 
3d.  Causes  preventing  passage  of  ovule  into  uterus. 

Stricture  or  obliteration  of  Fallopian  tubes ; 

Absence  of  Fallopian  tubes  ; 

Detachments  and  displacements  of  Fallopian  tubes. 
4th.  Causes  destroying  vitality  of  semen  or  preventing  fixation  of 
imprrgnated  ovum. 

Corporeal  or  cervncal  endometritis  ; 

Membranous  dysmenorrhcea ; 

Menorrhagia  or  metrorrhagia ; 
40 


626  STERILITY. 

Abnormal  growths ; 
Areolar  hyperplasia. 

The  mode  of  action  of  most  of  these  causes  is  so  self-evident  as 
to  make  anything  more  than  their  mention  unnecessary.  Some  of 
them,  however,  require  special  explanation. 

Va2::inismus  is  an  appellation  which  has  been  given  of  late  years 
to  a  hypersesthetic  state  of  the  ostium  vaginae,  which  results  in 
spasm  of  its  sphincter.  This  interferes  with  the  entrance  of  the 
male  organ,  and  consequently  of  seminal  fluid  into  the  vaginal 
canal ;  indeed,  in  aggravated  cases,  it  entirely  precludes  sexual 
approaches.  The  affection  is  by  no  means  rare,  and  is  a  fruitful 
source  of  sterility. 

An  abnormal  shape  of  the  cervix  has  been  pointed  out  by  Dr. 
Sims  as  a  frequent  cause  of  infecundity.     If  this  part  be  too  long, 
so  as  to  curl  or  bend  upon  itself,  it  is  evident 
Fig.  173.  that  it  may  not  admit  seminal  fluid  through 

its  canal.  But  even  a  slighter  degree  of 
elongation,  in  which  the  cervix  has  a  conical 
shape,  has  been  observed  to  be  frequently  fol- 
lowed by  that  condition.  My  own  experience 
leads  me  very  positively  to  the  conclusion 
that,  excepting  endometritis,  this  is  the  most 
common  of  all  the  causes,  and  fortunately  one 
of  the  most  remediable.  Fig.  173  represents 
the  variety  of  conoidal  cervix  generally  met 
Conoidai  cervix.    (Sims.)    with  as  productive  of  sterility. 

Endometritis,  whether  it  be  cervical  or 
corporeal,  fills  the  uterine  canal  with  a  thick,  tenacious  mucus, 
which  often  prevents  the  entrance  of  seminal  fluid  or  destroys  its 
vitality. 

Flexions  of  the  uterus,  by  producing  bending  of  the  cervical 
canal,  and  versions,  by  pressing  the  os  against  one  wall  of  the 
vagina  so  as  to  close  it  as  if  by  a  valve,  may  entirely  obstruct  the 
passage  to  the  uterus. 

Obliteration  and  displacement  of  the  tubes  frequently  result  from 
pelvic  peritonitis,  and  thus  that  affection  often  entails  sterility  of 
the  most  irremediable  character.  The  second  stage  of  the  disease 
consists  in  effusion  of  lymph,  which  in  time  undergoes  contraction, 
and  either  closes  these  canals  or  draws  them  out  of  place. 

Membranous  dysmonorrhooa,  or  rather  the  tendency  to  exfolia- 
tion of  uterine  mucous  membrane  which  characterizes  it,  so  alters 
the  uterine  surface  as  to  render  it  inapt  for  the  fixation  of  the  ovum. 


DIFFERENTIATION.  627 

Menorrhagia  and  metrorrhagia  may  result  in  the  washing  away 
of  the  ovum  after  impregnation  and  before  fixation.  The  normal 
menstrual  hemorrhage  occurs  before  the  entrance  of  the  ovule  into 
the  uterus.  If  it  be  excessive  and  prolonged,  it  may  remove  the 
ovule  entirely,  and  in  the  same  way  metrorrhagia  may  remove  the 
impregnated  ovum.  An  abortion  does  not  occur  under  these  cir- 
cumstances, for  although  impregnation  may  have  taken  place,  con- 
ception has  not  done  so. 

Abnormal  growths  of  any  form  which  fill  the  uterine  cavity,  as, 
for  example,  fibroids,  polypi,  hydatids,  or  moles,  may  so  interfere 
with  the  attachment  of  the  ovum  to  the  uterus,  as  to  prevent  con- 
ception even  when  impregnation  has  occurred. 

Although  it  is  impossible  to  give  positive  proof  of  the  fact  that 
serious  chronic  disease  of  the  ovaries  results  in  a  blighting  influence 
upon  the  ovule,  such  a  conclusion  is  rendered  highly  probable  by 
the  results  of  experience  in  such  cases.  Such  a  result  is  often  found 
to  attend  chronic  ovaritis,  general  pelvic  peritonitis  or  cellulitis, 
and  double  cystic  disease. 

Some  of  the  causes  here  enumerated  are  much  more  frequent  than 
others.  I  would  enumerate  the  most  common  causes  in  the  order 
of  their  frequency  in  the  following  sequence:  first,  glandular 
cervical  endometritis ;  second,  areolar  hj-perplasia,  the  result  of 
subinvolution  of  the  uterus;  third,  conoid  cervix,  with  contracted 
OS ;  fourth,  flexion  and  version  of  the  uterus ;  fifth,  contraction  of 
OS  externum ;  sixth,  fibroids,  interstitial,  or  submucous ;  seventh, 
menorrhagia  or  metrorrhagia  ;  and  eighth,  ovarian  incapacity  from 
chronic  ovaritis  or  pelvic  peritonitis.  I  do  not  state  this  sequence 
dogmatically,  but  merely  to  convey  an  idea  of  my  impressions  with 
reference  to  the  matter. 

Differentiation. — Before  it  is  determined  that  a  woman  is  sterile, 
the  sexual  capacity  of  the  husband  should  be  ascertained.  Men 
ure  averse  to  the  confession  of  impotence,  and  will  often  allow  the 
■iupposition  of  sterility  on  the  part  of  their  wives  to  be  maintained 
rather  than  admit  the  truth.  In  two  cases  I  have  used  an  anaes- 
thetic, ruptured  the  hymen,  and  distended  the  vagina,  under  the 
impression  that  sterility  of  several  years'  standing  was  due  to  the 
impossibility  of  the  accomplishment  of  intercourse,  and  have  sub- 
sequently discovered  that  the  husbands  of  my  patients  were  entirely 
impotent,  and  had  been  so  before  marriage. 

Prognosis. — In  reference  to  a  disorder  which  may  be  produced 
by  such  a  variety  of  causes,  no  positive  prognosis  can  be  given, 
for  its  cure  will  entirely  depend  upon  the  removal  of  the  agency 


628  STERILITY. 

which  produces  it.  Much,  too,  will  depend  upon  the  thorough 
investigation  of  the  causes  hy  tlie  physician,  and  a  proper  under- 
standing on  his  part,  of  the  treatment.  Unquestionahly  a  large 
proportion  of  sterile  women  may,  hy  appropriate  treatment,  be 
made  fruitful. 

Results. — No  physical  results  are  produced  by  sterility,  but  its 
existence  will  frequently  depress  the  spirits  and  sadden  a  disposi- 
tion which,  under  other  circumstances,  would  have  been  cheerful 
and  equable.  The  married  woman  has  always  regarded  and  will 
forever  view  this  incapacity  as  a  reproach  to  her  womanhood,  and 
no  amount  of  argument  can  make  her  accept  it  with  resignation. 

Treatment. — The  treatment  of  sterility  consists  in  the  removal  of 
its  causes.  Many  of  these  are  not  susceptible  of  remedy,  while  the 
means  of  treating  others  are  so  evident  that  special  mention  may 
be  confined  to  a  few.  Obturator  hymen,  vaginismus,  atresia  vaginne, 
and  occlusion  of  the  cervical  canal  should  be  treated  bj^  the  surgical 
operations  appropriate  to  each. 

In  case  the  vaginal  cervix  should,  to  only  a  limited  extent,  be 
too  projecting  or  conical,  the  bilateral  operation  for  its  enlarge- 
ment should  be  practised  after  the  method  elsewhere  described. 
If  a  slight  constriction  of  the  cervical  canal  appear  to  l)e  the 
cause  of  the  condition,  dilatation  may  be  essayed  in  place  of  a 
surgical  procedure.  In  an  aggravated  case,  when  the  neck  ])roject8 
markedly  and  is  decidedly  conoidal  in  shape,  both  these  means  are 
insufficient;  amputation  then  becomes  necessary.  After  this  has 
been  recovered  from,  the  bilateral  operation  for  cervical  hysterotomy  i 
is  often  necessary  before  cure  is  effected.  In  this  connection  the  > 
chapters  upon  dysmenorrhoea  and  amj)Utation  of  the  cervix  sljould 
be  referred  to.  Endometritis,  whether  of  body  or  cervix,  should  be 
appropriately  treated,  and  al^normal  growths  should  be  dealt  with 
as  if  sterility  did  not  exist. 

If  a  displacement  be  discovered  and  replacement  and  retention 
be  possible,  they  should  be  practised.  But  if  in  case  of  flexion  thisi 
be  impossible,  the  uterine  canal  should  be  rendered  as  straight  as  isH 
practicable,  by  the  cervical  incision  recommended  by  Dr.  Sims  for ' 
dysmenorrhoea.  Menorrhagia  and  metrorrhagia  should  be  treated 
upon  the  plan  recommended  in  the  chapter  upon  those  subjects,  and  I 
the  patient  be  advised  to  keep  very  quiet  and  to  avoid  warm  and  ' 
stimulating  beverages  durinsr  menstrual  epochs. 

A  remark  made  in  conueetlon  with  the  treatment  of  leucorrhoBaj 
may  with  propriety  be  repeated  here,  namely,  that  to  enter  morel 


AMPUTATION    OF    THE    NECK    OF    THE    UTERUS.  629 

minutelj  into  the  study  of  special  remedial  measures  would  tend 
to  divert  the  mind  of  the  reader  from  a  point  whicli  I  regard  as 
of  paramount  importance ;  that  this  affection  is  commonly  only 
a  symptom  Avhich  should  be  reached  through  the  malady  which 
induces  it. 

In  spite  of  the  fact  that  we  have  at  our  disposal  many  valuable 
resources  for  the  removal  of  the  causes  which  create  sterility,  were 
I  asked  to  mention  the  part  of  the  field  of  gynecology  which 
yielded  me  the  least  satisfaction  and  the  greatest  disappointment,  I 
should  cite  this. 


CHAPTER    XLII. 

AMPUTATION  OF  THE  NECK  OF  THE  UTERUS. 

Under  certain  circumstances  where  it  is  impossible  to  overcome 
morbid  conditions  of  the  cervix  uteri  by  medicinal  measures, 
amputation  of  this  part  is  practised.  As  a  description  of  the 
operation  has  not  been  called  forth  by  any  division  of  our  subject 
which  has  thus  far  been  treated,  it  will  be  well  to  allot  a  place  to 
it  here  before  leaving  the  consideration  of  uterine  and  taking  up 
that  of  ovarian  diseases. 

History. — Ambrose  Pard*  was  the  first  surgeon  who  advised 
amputation  of  the  cervix.  He  recommended  it  in  malignant 
growths  of  the  part,  to  which,  he  says,  "  we  may  apply  the  specu- 
lum matricis,  in  order  to  see  more  easily."  It  is  reported,  upon 
insufficient  authority,  to  have  been  performed  as  early  as  1652,  by 
Tulpius,  of  Amsterdam,  and  in  1766,  by  La  Peyronie.  Daniel 
Turner,^  of  London,  in  1736,  reported  an  instance  in  which  the 
neck  of  a  prolapsed  uterus  was  amputated  by  means  of  a  razor  in 
the  hands  of  the  patient  herself,  who  was  insane.  The  recovery 
of  the  woman  was  evidently  regarded  as  a  wonderful  circumstance. 
In  1802,  the  operation  was  systematized  by  Osiander,  who  per- 
formed it  twenty-three  times,  and  after  this  it  was  resorted  to  by 
Dupuytren,  Recamier,  Hervez  de  Chegoin,  and  others.     It  was, 


CEuvres  d'Ambroise  Par6,  lib.  xxiv,  p.  1012. 
N.  Y.  Med.  Jouni.,  vol.  v,  No.  5. 


630  AMPUTATION    OF    THE    NECK    OF    THE    UTERUS. 

however,  in  the  hands  of  Lisfranc  that  it  attracted  special  atten- 
tion,  and  in  consequence  of  his  enthusiasm  it  was  for  a  time  re- 
o:arded  as  a  means  which  was  destined  to  accomplish  a  vast  deal 
of  good.  His  reports  of  its  results  were  most  favorable,  and  he 
described  its  dangers  as  slight.  But  soon  after  his  publications 
upon  it  there  appeared  a  counter-report  from  the  young  pliysician^ 
who  took  charge  of  many  of  his  cases  and  was  familiar  with  all, 
which  cast  discredit  upon  all  the  master's  statements.  By  Pauly, 
the  truth  was,  as  Becquerel  expresses  it,  "  brutally  revealed,"  and 
it  was  entirely  at  variance  with  the  representations  of  Lisfranc. 
Since  that  time  the  operation  has  to  a  certain  extent  fallen  into 
disrepute,  but  is  still  resorted  to  in  api)ropriate  cases. 

Dangers. — The  dangers  of  the  procedure  are  the  following: 

Primary  hemorrhage ; 
Secondary  hemorrhage ; 
Peritonitis; 
Cellulitis ; 
Tetanus. 

The  statistics  of  the  operation  have  not  as  yet  been  carefully 
collected.  Lisfranc  reported  99  operations  and  only  two  deaths, 
but  these  statements  Pauly  renders  more  than  doubtful.  Huguier 
reports  13  operations  and  no  deaths ;  Sims  over  50  operations  and 
one  death ;  and  Simpson  8  operations  and  one  death. 

Even  these  reports,  favorable  as  they  are,  refer  to  the  results  of 
amputation  by  the  knife.  By  galvano-cautery  much  better  results 
are  obtained.  It  is  really  surprising  to  see  how  little  constitutional 
disturbance  follows  this  operation.  Out  of  the  large  experience  of 
Dr.  Byrne,  of  Brooklyn,  with  it,  no  fatal  case  is  reported ;  and  not 
one  bad  result  has  occurred  in  my  own  practice  in  over  twenty  am- 
putations of  the  whole  cervix. 

Conditions  deynanding  Amputation. — The  conditions  which  ordi- 
narily call  for  removal  of  the  cervix  are  the  following : 

Malignant  disease ; 

Great  enlargement  from  cervical  hyperplasia ; 

Longitudinal  cervical  hypertrophy  ; 

Conical  and  projecting  cervix  ; 

Granular  or  cystic  degeneration  of  intractable  character. 

One  of  these  conditions,  longitudinal  cervical  hypertrophy,  not 
having  previously  received  special  mention,  requires  it  here.     The 


Pauly,  Maladies  de  I'Utferus,  Paris.  1836. 


METHODS    OF    PERFORMANCE.  031 

cervix  may  be  congenitally  very  inucli  elongated  l)elow  the  vaginal 
junction.  Generally  it  undergoes  h^-pertrophic  elongation  from  a 
simple  formative  irritation,  a  low  grade  of  cervical  endometritis, 
congestion  long  kept  up,  or  prolapsus  in  the  third  degree.  Under 
these  circumstances  the  neck  grows  very  long,  so  as  to  rest  between 
ihe  labia  or  even  to  project  for  a  number  of  inches  from  the  body, 
and  has  in  some  instances  been  mistaken  for  the  penis.  By  means 
of  the  touch,  conjoined  manipulation,  the  speculum,  and  the  probe, 
a  diagnosis  can  readily  be  made.  M.  Huguier,  some  years  ago, 
maintained  that  this  condition  often  deceived  practitioners  into 
the  belief  in  prolapsus  uteri. 

Varieties  of  the  Operation. — In  some  cases,  as  in  cancer,  for  ex- 
ample, it  is  necessary  to  remove  the  entire  cervix  and  even  as 
much  tissue  as  possible  from  that  portion  of  the  organ  above  the 
vaginal  attachment.  In  others,  only  half  of  the  vaginal  portion 
requires  ablation,  while  in  still  another  set  of  cases,  only  the  re- 
moval of  a  thin  section  of  the  hypertrophied  lips  is  called  for. 

Methods  of  Performance. — The  operation  may  be  performed  by 
the  following  methods: 

By  the  bistoury  or  scissors ; 

By  the  dcraseur ; 

By  the  galvano-caustic  battery. 

Operation  by  Bistoury  or  Scissors. — When  performed  by  the  first 
method,  the  patient  should  be  placed  upon  the  left  side  and  Sims's 
speculum  employed.  The  cervix  being  slit  bilaterally,  one  lip  is 
seized  and  cut  off  as  near  the  vaginal  junction  as  is  deemed  advisa- 
ble, and  then  the  other  is  removed  in  a  similar  manner.  Formerly 
the  operation  was  completed  at  this  point,  but  Dr.  Sims  has  in- 
troduced the  practice  of  drawing  down  the  mucous  membrane  and 
stitching  it,  with  silver  sutures,  so  as  to  cover  the  stump,  as  that 
of  the  arm  or  thigh  is  covered  by  skin  after  amputation  of  those 
parts.  When  the  stump  is  covered  by  mucous  membrane,  after 
this  plan,  recovery  is  much  more  rapid  than  when  granulation  is 
illowed  to  accomplish  the  cure.  This  operation  is  often  a  bloody 
one. 

Operation  by  the  Ecraseur. — In  operating  by  this  method,  if  the 
uterus  be  prolapsed,  or  if  the  degree  of  longitudinal  hypertrophy 
be  so  excessive  as  to  cause  full  protrusion  of  the  cervix,  or  if  such 
protrusion  be  attainable  by  moderate  traction,  the  patient  may  be 
placed  on  the  back.  If  the  uterus  be  high  up  in  the  pelvis  and 
strong  traction  be  necessary  to  depress  it,  the  best  position  will  be 


632 


AMPUTATION  OP  THE  NECK  OF  THE  UTERUS, 


found  to  be  that  advised  when  scissors  or  tlie  bistoury  are  em- 
ployed, the  speculum  being  used.  The  passage  of  the  cliain  will 
be  found  to  be  very  simple,  and  the  part  should  be  slowly  cut 
through. 

In  using  the  ^craseur  for  this  purpose,  great  care  should  be 
observed  not  to  allow  of  too  great  dragging  of  the  chain  upon  the 
neck  without  cutting.  If  attention  be  not  given  to  this  point,  the 
peritoneum  may  be  opened  or  the  bladder  involved. 

Operation  by  Galvano-Cautery. — The  gal va no-caustic  apparatus 
consists  simply  of  an  instrument  which  enables  the  operator  to 
engage  any  part  in  a  loop  of  wire  which,  being  connected  with  a 
powerful  galvanic  battery,  becomes  white  hot  and  cuts  its  way 

Fiir.  174. 


Byrne's  galvano-caustic  battery.' 

through.     The  instruments  generally  employed  here  are  a  German    ' 
battery,  Middledorpf 's,  or  Grennett's  ;  a  very  compact  instrument     ; 

■  For  details  concerning  this  instrument  I  refer  the  reader  to  Pr.  Byrne's  inter- 
esting brochure  entitled  Electro-cautery  in  Uterine  Surgery,  Wm.  Wood  &  Co. 


OPERATION    BY    THE    GAL V AXO-CAUTERY.  633 

made  in  London ;  and  one  constructed  by  W.  F.  Ford,  of  ^ew 
York,  after  a  method  suggested  by  Dr.  John  Byrne.  It  would  be 
out  of  place  here  to  give  details  concerning  these  instruments;  all 
of  tliera  answer  the  purpose  in  view  very  well.  That  of  Dr.  Byrne 
is,  for  an  American,  most  attainable,  and  is  certainly  a  very  efficient 
and  reliable  apjjaratus.     It  is  shown  in  Fig.  174. 

In  amputating  the  neck  in  this  way,  the  patient  may  be  placed 
upon  the  back,  and  the  uterus  drawn  down  between  the  labia;  or 
if  this  depression  of  it  be  difficult,  she  may  be  placed  upon  the 
side,  and  Sims's  speculum  employed.  By  one  of  these  procedures 
the  part  to  be  amputated  is  fairly  exposed  to  view  and  manipula- 
tion. The  wire  loop  of  the  galvano-cautery  is  passed  around  the 
nock  as  high  up  as  is  deemed  safe,  and  tightened  until  it  is  fixed 
in  the  tissues  so  as  not  to  slip.  Then  the  current  of  electricity  is 
made  to  pass  through  it,  and  the  loop  being  slowly  tightened  by 
tlie  turning  of  a  screw  by  the  operator  the  cervix  is  amputated. 

The  effect  of  the  heat  upon  the  divided  tissues  differs  according 
to  its  intensity ;  if  the  wire  becomes  heated  to  whiteness,  there  is 
scarcely  any  effect  upon  the  tissue,  for  the  parts  being  in  consequence 
so  much  more  quickly  divided  the  heat  has  not  time  to  radiate, 
whilst,  if  the  wire  be  only  red  hot,  an  eschar  is  formed  from  one 
to  three  lines  in  thickness,  in  consequence  of  the  coagulation  of  the 
albumen  of  the  tissues.  After  the  operation  the  prolapsed  parts 
are  pushed  back  into  the  pelvis,  and  the  patient  kept  quiet  in  the 
recumbent  position  for  six  or  seven  days.  Vaginal  injections  of 
water,  or  water  and  a  small  quantity  of  carbolic  acid,  is  the  only 
local  treatment  applied.  There  being  no  hemorrhage,  styptics  are 
unnecessary.  The  appearance  of  the  divided  surface  resembles  that 
of  a  raw  potato  cut  with  a  dull,  rough,  and  slightly  rusty  knife. 

My  experience  in  the  use  of  this  instrument  for  amputation  of 
the  neck  of  the  uterus  and  parts  about  the  vulva  is  quite  large,  and 
I  feel  convinced  that  where  the  galvano-caustic  apparatus  is  obtain- 
:il»le  it  should  by  all  means  receive  the  preference  over  either  the 
>eissors  or  the  ecraseur.  After  the  use  of  the  first  of  these,  hemor- 
rhage of  uncontrollable  character  is  apt  to  occur,  and  the  second 
not  only  crushes  the  tissues,  but  sometimes  draAvs  into  the  field  of 
amputation  important  surrounding  parts.  The  results  of  operation 
after  electro-cautery  are  also  much  better  than  after  the  other 
methods,  septic  absorption  with  its  numerous  consequences,  and 
hemorrhage  both  immediate  and  remote,  being  by  it  very  perfectly 
prevented. 


034  DISEASES    OF    THE    OVARIES. 


CHAPTER    XLIII. 

DISEASES  OF   THE  OVARIES. 

History. — Ancient  literature  is  singularly  barren  upon  the  sub- 
ject of  ovarian  diseases.  That  the  functions  of  these  organs  were 
known  to  early  anatomists,  there  is  no  doubt,  for  as  early  as  200 
B.  C.  the  operation  of  castration  of  female  animals  is  alluded  to  by 
Aristotle,  and  in  the  second  century  A.  C.  they  were  described  by 
Galen  under  the  name  of  "  testes  muliebres."  As  to  the  influence 
exerted  by  tliem  upon  menstruation,  they  were  not  informed,  for 
they  attributed  that  process,  according  to  Aristotle,  to  a  superfluity 
in  the  blood,  an  opinion  which  was  entertained  even  by  Hippocrates. 
The  works  of  Aetius  make  no  mention  whatever  of  ovarian  dis- 
orders, and  those  of  Paul  of  u^gina  are  equally  silent.  When  it  is 
borne  in  mind  that  the  ovular  theory  of  menstruation  dates  back 
for  its  origin  to  the  labors  of  N^grier,  Gendrin,  Bischoft",  Pouchet, 
and  others  of  our  own  time,  and  that  the  operation  of  ovariotomy 
was  never  systematically  performed  before  the  year  1809,  it  will  be 
a})preciated  how  recently  the  profession  even  in  modern  times  has 
fully  grappled  with  the  subject. 

During  the  past  ten  or  fifteen  j'cars  full  amends  have  been  made 
for  this  delay  in  progress,  for  since  that  time  no  portion  of  the  field 
of  gynecology  has  received  more  attention  or  been  more  thoroughly 
investigated  than  that  which  now  engages  us.  i^J^ot  only  have 
most  of  the  diseased  conditions  of  the  ovaries  been  satisfactorily 
investigated,  and  the  diagnosis  of  them  reduced  to  a  scientific 
system ;  for  the  most  frequent  and  important  of  them  surgical  means 
have  been  instituted  with  such  success  as  to  have  given  procedures 
of  the  most  appalling  character  and  undoubted  dangers,  the  posi- 
tion of  legitimate  and  justifiable  operations.  The  recent  literature 
of  ovarian  pathology  and  surgery  is  now  enriched  by  the  contribu- 
tions of  so  many  capable  observers,  that  it  is  almost  invidious  to 
particularize  the  most  prominent.  Unfortunately  there  is  one  set 
of  ovarian  aftections  with  reference  to  which  these  statements  are 
not  true;  those  of  inflammatory  character.     Our  means  of  diagnp- 


ANATOMY    OF    THE    OVAKIES. 


63^ 


1 


sis  of  ovaritis,  both'  acute  and  chronic,  is,  in  spite  of  all  the  ad- 
vances alluded  to,  so  elementary  and  unreliable  that  the  result  is 
discordance  of  views,  and  uncertainty  as  to  pathology  and  thera- 
peutics. It  was  probably  the  contemplation  of  this  fact  which  led 
Scanzoni  to  open  his  article  upon  diseases  of  the  ovaries  with  the 
following  sentence:  "If  we  felicitate  ourselves  upon  the  progress 
which  has  been  made  during  the  last  few  years,  in  the  diagnosis 
and  treatment  of  the  diseases  of  the  uterus,  we  should,  on  the 
other  hand,  remember  that  the  labors  of  gynecologists  in  respect 
to  the  diseases  of  the  ovaries  have  been  almost  fruitless  in  practical 
results." 

In  illustration  of  the  difficulties  attending  the  diagnosis  of 
ovarian  diseases,  I  introduce  a  table  which  I  have  constructed  from 
Hennig's^  report  of  one  hundred  post-mortem  examinations  made 
by  him,  with  special  reference  to  this  point.  "  If  we  now  turn  our 
attention,"  says  he,  "•  to  the  diseases  of  the  ovaries,  it  is  a  fact  of 
great  value,  in  reference  to  diagnosis,  that  in  ten  out  of  one  hun- 
dred cases,  the  diseased  state  of  the  ovary  was,  or  might  have  been, 
recognized  during  life — more  frequently  by  rectal  exploration  than 
by  vaginal  or  abdominal."  On  the  other  hand,  out  of  81  bodies,  a 
diseased  condition  of  the  ovaries  was  found  in  53,  a  proof  of  how 
frequently  disease  of  the  ovaries  cannot  be  recognized  during  life. 
The  diseased  condition  was  more  frequent  in  one  ovary  alone  than 
in  both ;  three-fourths  of  the  cases. 


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Anatomy  of  the  Ovaries. — The  ovaries  are  two  follicular  glands 
I'about  the  shape  and  size  of  small  almonds,  situated  one  on  each 
[nde  of  the  uterus.     So  dependent  are  they  upon  the  position  of  the 


'  Catarrh  of  Sexual  Organs  of  the  Female.     By  Carl  Hennig. 


636  DISEASES    OF    THE    OVARIES. 

uterus  and  surrounding  viscera  that  they  have  really  no  fixed  place. 
They  are  usually  found  in  the  lateral  and  posterior  parts  of  the  true 
pelvis,  about  an  inch  from  the  uterus,  and  just  below  the  point 
where  the  Fallopian  tubes  enter  that  organ,  the  left  being  in  close 
proximity  with  the  rectum.  Each  ovary  is  attached  to  the  peri- 
toneum, which  connects  it  with  adjacent  structures,  and  is  firmly 
united  with  the  uterus  by  means  of  a  fibrous  cord  arising  from  the 
horn  of  each  side. 

The  Fallopian  tube  of  each  side  is  connected  with  the  ovary  by 
one  fimbria,  and  acts  at  periods  of  ovulation  as  its  excretory  duct. 
The  surface  of  the  ovary  is  not  covered  by  peritoneum,  for,  arrived 
at  the  circumference  of  these  organs,  this  membrane  loses  its  charac- 
teristic a})pearances,  and  the  only  trace  of  it  which  is  discoverable 
is  a  layer  of  basement-epithelium.^  Around  the  circumference  of 
the  ovaries  a  cortical  portion  exists,  whose  duty  it  is  to  generate 
the  Graafian  follicles.  ^Vithin  this  is  a  fibrous  structure,  composed 
of  muscular  fibres,  cellular  tissue,  vessels,  and  nerves,  which  receives 
the  name  of  stroma.  Removed  from  the  stroma  and  examined 
with  care  by  the  microscope,  each  of  the  Graafian  vesicles  is  found 
to  consist  of  a  sac,  called  the  tunic,  which  is  filled  with  fluid,  the 
liquor  folliculi,  in  which  is  contained  the  ovum  or  egg  which  is  the 
female  contribution  to  conception. 

It  is  now  accepted  as  a  fact  by  most  physiologists,  although 
still  contested  by  some,  that  the  periodical  discharge  of  blood  from 
the  uterus,  which  is  called  menstruation,  is  merely  a  uterine  symp- 
tom of  the  discharge  of  one  of  the  ova  from  the  ovary  by  rupture 
of  a  follicle.  After  the  period  of  puberty  has  arrived,  one  or  more 
of  the  follicles  of  each  ovary  burst  every  month  by  the  following 
process:  a  congestion  or  hyperaemia  occurring  in  the  ovary  for 
some  reason  beyond  our  comprehension,  causes  an  excessive  secretion 
by  the  walls  of  the  follicle,  in  which  a  miniature  dropsy  takes  place. 
This  goes  on  to  rupture,  and  escape  of  the  liquor  folliculi,  blood,  | 
granular  cells  lining  the  ovisac,  and  the  ovum.  The  nervous  supply 
to  both  uterus  and  ovaries  is  excited  by  this  process,  and  one  of  the  t 
results  of  such  excitement  is  contraction  of  the  delicate  middle  \ 
layer  of  uterine  fibres  which  surround  the  network  of  minute  ves- 
sels enveloping  and  penetrating  the  uterine  structure.  This  throws 
the  vascular  apparatus  into  a  state  of  erection.  Great  engorgement 
occurs  on  the  surface  of  the  uterine  mucous  membrane,  and  prob- 

'  For  details  with  regard  to  these  curious  and  recently  discovered  facts,  the  reader   f 
is  referred  to  essays  by  Otto  Scbruue,  Henle,  and  Sappey. 


VARIETIES    OF    OVARIAN"    DISEASE.  637 

ably  on  that  lining  the  Fallopian  tubes ;  they  rupture,  and  a  flow 
of  blood  takes  place.  Three  elements  are  concerned  in  this  dis- 
charge: 1st,  ovarian  irritation  excited  by  ovulation  and  transmitted 
to  the  nerves  governing  the  muscles  constituting  the  middle  coat 
(if  uterine  tibres;  2d,  erection  of  the  uterine  vascular  system;  3d, 
consequent  rupture  of  the  bloodvessels  of  the  mucous  membrane 
of  the  uterus  and  escape  of  blood.  The  ovisac  being  thus  emptied 
a  clot  of  blood  soon  forms  within  it,  then  an  hypertrophy  of  the 
cells  lining  it  occurs,  and  the  corpus  luteum  is  formed. 

If  the  examiner  hold  up  one  of  the  broad  ligaments  between 
himself  and  the  light,  a  small  plexus  of  white,  crooked  tubes  will 
l)e  seen  forming  a  cone,  the  apex  of  which  is  directed  towards  the 
hilus  of  the  ovary.  It  measures  about  an  inch  in  breadth,  and 
consists  of  about  twenty  tubes  which  are  filled  with  a  clear  fluid. 
This  is  the  organ  of  Rosenmiiller,  which  has  recently  been  minutely 
ilescribed  b}^  Kobelt  under  the  name  of  the  par-ovarium,  and  is 
supposed  by  him  to  be  an  exaggeration  of  the  Wolfiian  body.  The 
exact  location  of  the  par-ovaria  is  this:  they  lie  beneath  the  ovaries 
and  between  the  ultimate  folds  of  the  peritoneum  covering  the 
fimbriated  extremities  of  the  Fallopian  tubes,  which  have  received 
the  name  of  the  alse  vespertilionum. 

The   ovaries   are   supplied  with   blood   through   the   spermatic 

irteries,  which,  upon  arriving  at  the  margin  of  the  pelvis,  pass 

j  inwards  between  the  layers  of  tlie  broad  ligaments,  and  thus  reach 

i  their  lower  border.     Their  nervous  supply  is  not  extensive,  and 

>  derived  from  the  renal  plexus. 

The  ovary  presents  its  most  perfect  type  in  the  young  virgin, 
A'lien  its  dimensions  are  greatest  and  its  surface  undeformed  by 
he  numerous  cicatrices  which  appear  at  a  later  period.  The 
limensions  of  this  organ  are  greater  than  they  are  during  early 
"irgin  life  only  during  and  for  six  weeks  after  the  process  of  utero- 
lestation.  Ilennig,  who  has  made  a  special  and  exceedingly 
;  ninute  study  of  this  point,  declares  that  pregnane}^  increases  the 
ength  but  not  the  breadth  nor  the-  thickness  of  the  organ.  Utero- 
\station,  which  leaves  the  uterus  larger  than  it  was  before,  has 
he  contrar}^  effect  upon  the  ovaries,  which  after  its  accomplish- 
iient  diminish  in  size,  never  again  to  attain  their  former  dimen- 
ions  while  in  a  state  of  health. 

'  Varieties  of  Ovarian  Disease. — Any  one  or  all  of  the  tissues  which 
ave  been  mentioned  may  be  affected  by  disease,  or  the  position 
f  the  ovary  may  be  altered  to  such  an  extent  as  to  constitute  a 


638  DISEASES    OF    THE    OVARIES. 

m 
morbid  state.     The  following  table  presents  a  list  of  the  disorders    1 
of  these  glands  which  will  now  receive  special  attention : 

Absence ; 

Imi:)erfect  development ; 

Atrophy;  11 

Inflammation ;  ' ' 

Neoplasms. 

Absence. 

One  or  both  of  the  ovaries  may  be  congenitally  absent,  but 
such  a  condition  is  very  rare.  When  it  does  exist,  it  is  generally 
only  a  part  of  a  complete  want  of  genital  development  which  is 
manifested  not  only  by  these  organs  but  by  the  parts  making  up 
the  vulva,  the  vagina,  and  the  uterus.  Kiwisch  declares  that  it 
has  been  most  frequently  observed  in  the  bodies  of  newly-born 
infants  who  were  not  vial)le  on  account  of  complicated  deformities. 
Where  there  is  congenital  absence  of  the  ovaries  the  woman  is 
generally  small  in  stature,  her  figure  undeveloped,  as  if  the  period 
of  girlhood  were  abnormallj'  prolonged,  and  the  genital  system  < 
imperfect,  as  already  mentioned.  In  some  cases  the  mind  is  very 
deficient,  a  condition  bordering -upon  idiocy  sometimes  existing. 
In  others  this  is  not  the  case,  but  the  patient  suffers  from  depres- 
sion of  spirits,  and  appears  to  lack  vigor  both  of  mind  and  body. 
Development  into  womanhood  has  never  arrived  for  her,  and  she 
remains  a  child  without  the  vivacity  and  cheerfulness  of  childhood. 

Although  certainty  can  only  be  arrived  at  post-mortem,  a  diag- 
nosis may  be  made  during  life  l)y  the  use  of  Simon's  method,  which 
may  guide  us  in  prognosis  and  treatment.  Indeed,  one  of  the 
s-reatest  benefits  which  can  accrue  from  a  correct  conclusion  will  i 
consist  in  the  avoidance  of  all  eftbrts  which,  being  vainly  addressed  I 
to  exciting  the  performance  of  the  functions  of  the  ovaries,  deterio- 
rate the  state  of  the  patient.  Should  the  general  condition  of  the 
patient,  the  undeveloped  state  of  the  vulva,  vagina,  and  uterus, 
and  the  entire  absence  of  the  menstrual  crisis  combine  as  evi- 
dences of  the  condition,  a  diagnosis  is  admissible. 

Imperfect  Development. 

This  condition,  which  consists  in  persistence  of  the  foetal  state  i 
of  these  organs  after  the  period  of  puberty  when  rapid  develop- 
ment should  have  occurred,  is  by  no  means  so  rare  as  that  just  i  ,. 


IMPEEFECT  DEVELOPMENT.  689 

mentioned.  It  may  exist  on  one  side  only,  though  it  generally 
affects  both.  As  in  the  case  of  absence  of  the  ovaries,  a  certain 
conclusion  is  not  easy,  and  as  in  that  case,  also,  we  draw  a  pre- 
sumptive conclusion  from  want  of  development  in  the  other  organs 
of  generation,  absence  of  tlie  usual  signs  of  the  menstrual  crisis, 
and  lack  of  general  constitutional  vigor  and  development. 

As  examples  of  cases  susceptible  of  such  an  explanation  I 
record  the  histories  of  two  with  which  I  have  recently  met.  The 
Urst  is  that  of  Miss  F.,  referred  to  me  by  Dr.  Eodenstein,  of 
Manhattanville.  She  is  twenty-four  years  of  age,  and  yet  has  the 
appearance  of  a  girl  of  thirteen.  Indeed,  it  is  diiRcult  to  believe 
the  statement  that  she  is  more  than  that  age.  The  features,  limbs, 
mode  of  expression,  and  general  deportment  are  those  of  a  child. 
She  has  never  menstruated  nor  shown  any  evidences  of  a  tendency 
to  do  so.  Physical  exploration  shows  the  vulva  in  the  state  of 
early  girlhood,  the  mons  veneris  destitute  of  hair,  the  labia  thin, 
and  the  vagina  so  small  and  narrow  that  the  little  finger  only  can 
1)0  introduced,  and  that  causes  o-reat  sufferina;.  The  canal  boino- 
sliort  as  well  as  narrow,  the  uterus  can  be  touched,  and  is  found 
like  a  little  nu^  in  the  vagina,  so  light  that  its  weight  is  scarcely 
[lerceptible. 

The  second  case  is  one  which  I  saw  with  Prof.  W.  H.  Thomp- 
son. The  patient  is  eighteen  years  old,  and  has  never  menstruated. 
Previous  to  the  treatment  established  by  Dr.  Thompson,  she  suf- 
fered greatly  from  epileptic  seizures,  which  have  evidently  impaired 
he  force  of  her  intellect,  but  during  the  past  two  months  she  has 
)een  free  from  them.  The  girl  is  slow  in  her  movements,  childish 
n  manner,  and  stupid  in  replying  to  questions.  Upon  2)hysical 
xploration,  the  vulva,  vagina,  and  uterus  are  found  fully  and  per- 
ectly  developed,  the  latter  giving  by  measurement  with  the  uterine 
■robe,  two  and  a  half  inches.  Nothing  can  be  elicited  with  refer- 
nee  to  the  ovaries  by  physical  means,  but  the  rational  signs 
lentioned,  together  with  the  fact  that  all  the  ajopearances  of  girl- 
ood  are  combined  with  entire  absence  of  any  apparent  effort  at 
vulation,  render  the  supposition  that  the  ovaries  are  undeveloped, 
r  foetal,  highly  probable. 

Sometimes  cases  will  be  met  with  in  which  masculine  develoi> 
tent,  emansio-mensium,  and  sterility,  will  lead  to  a  diagnosis  of 
tsence  of  the  ovaries,  but  which  will  subsequently  undergo  a 
lange  and  give  all  the  evidences  of  the  presence  and  efficiency 
;'  these  organs.     One  such  case,  which  occurred  in  the  practice 


640  DISEASES    OF    THE    OVARIES. 

i 

of  Dr.  Metcalfe  and  myself,  is  worthy  of  record.  Mrs.  B.,  a  large, 
muscular,  and  handsome  woman,  had  menstruated  very  irregularly 
and  scantily  for  ten  or  fifteen  years.  Sometimes  the  menstrual 
discharge  would  be  entirely  absent  for  months,  then  it  would  at 
long  and  irregular  intervals  show  itself  for  a  day.  Her  health 
was  not  affected  by  this  in  any  way.  She  presented,  however, 
many  signs  of  masculinity ;  the  voice  was  harsh,  the  breasts  flat, 
and  the  chin  covered  with  a  sjjarse  beard.  After  having  been 
married  for  years  she  became  pregnant,  and  in  due  time  bore  a 
child,  subsequent  to  which  she  menstruated  more  regularly  and 
plentifully,  and  has  since  borne  two  children. 

Treatment. — Should  the  ovaries  be  congenitally  absent,  it  is 
evident  that  art  can  do  nothing  to  remedy  the  evil.  Should  they 
exist  in  an  undeveloped  or  foetal  state,  it  is  possible  that  by  a 
proper  stimulus  applied  to  them  by  the  most  direct  means  in  our 
power,  growth  and  maturity  may  be  fostered,  unless  the  condition 
be  one  of  aggravated  arrest  of  development.  The  means  which 
are  most  likely  to  accomplish  this  are : 

General  tonics ;  ^ 

Uterine  irritation  ; 

Electricity' ; 

Marriage.  u 

The  sanguineous  and  nervous  systems  should  both  be  brought 
into  as  perfect  a  state  of  health  as  possible  by  ferruginous  and 
bitter  tonics,  fresh  air,  exercise,  change  of  scene,  and  a  general 
observance  of  the  laws  of  hygiene. 

The  most  direct  method  for  irritating  the  ovaries  is  through  the 
uterus,  with  which  so  close  a  sympathy  exists.  For  this  purpose 
tents  may  be  occasionally  resorted  to,  as  often,  for  instance,  a& 
once  or  twice  a  month.  Tliis  not  only  prepares  the  uterus  for  its 
part  of  the  process  of  menstruation,  but  causes  a  hyperemia  in  t 
the  ovaries,  which  we  know  to  be  the  physiological  forerunner  of 
ovulation. 

Electricity  may  be  employed  by  placing  one-  pole  of  a  battery 
over  the  spine  and  one  over  the  ovaries,  or,  more  effectually,  by 
carrying  one  pole,  protected  where  it  touches  the  vagina,  to  the 
cervix  uteri,  connecting  this  with  a  battery,  and  passing  the  other 
pole  over  the  ovaries.  An  intra-uterine  galvanic  pessary  may  like- 
wise answer  a  good  purpose,  when  worn  steadily  and  persistently. 

The  ovarian  irritation  and  congestion  incident  to  the  marital  act 


ATROPHY.  641 

will  sometimes  excite  ovulation,  not  at  the  moment  of  coition,  as 
was  formerly  supposed,  but  remotely. 

Atrophy  of  the  Ovaries. 

At  a  period,  varying  from  the  fortieth  to  the  fiftieth  year,  the 
ovaries  are  destined  to  undergo  atrophy.  They  diminish  in  volume, 
become  wrinkled,  the  Graafian  follicles  disappear,  and  the  stroma 
becomes  dense  and  non-vascular.  This  is  a  physiological  process, 
and  marks  what  is  termed  the  menopause,  or  period  of  menstrual 
cessation.  Sometimes  tliis  process  sets  in  at  a  very  early  period, 
owing  to  some  abnormal  condition  which  has  excited  it,  and  pro- 
duces the  same  results  as  those  following  it  when  it  takes  place  at 
the  normal  time. 

Causes. — With  regard  to  the  special  causes  of  this  occurrence 
very  little  is  absolutely  known,  further  than  the  fact  that  it  some- 
times occurs  from  pelvic  inflammations.  It  is  probable  that  acute 
ovaritis  may  produce  it,  and  it  is  certain  that,  at  times,  it  results 
from  pelvic  peritonitis  and  cellulitis. 

The  following  case  which  presented  itself  at  my  clinique  some 
time  ago  is  illustrative  of  this  fact.  Mary  G.,  a  healthy  young  Irish 
woman,  aged  24  years,  stated  that  she  had  a  miscarriage  at  the  third 
menstrual  period,  five  years  before,  in  Albany.  Three  days  after 
the  product  of  conception  had  been  cast  oiF,  she  was  taken  with  a 
chill,  with  violent  pain  over  the  al)donien,  and  was  declared  by  her 
physician  to  have  inflammation  of  the  bowels.  "Of  this  attack  she 
nearly  died,  but  after  a  confinement  to  bed  for  six  weeks  grew 
1)etter.  For  two  years  after  this  she  had  irregular,  jjainful,  and 
[irofuse  menstruation.  As  she  expressed  it,  whenever  she  became 
fatigued  or  excited,  flooding  would  come  on.  After  this  time  the 
meiistrual  periods  disappeared,  and  she  now  applied  for  relief  on 
account  of  amenorrhoea  of  three  years'  standing.  Physical  explora- 
tion revealed  the  uterus  in  normal  position,  though  diminished  in 
size  to  about  two  inches.  Nothing  could  be  ascertained  about  the 
ovaries. 

The  view  which  I  took  of  the  case  was  that  pelvic  peritonitis 
and  acute  ovaritis  originally  existed;  'these  left  the  parts  in  such  a 
state  til  at  for  two  3'ears  metrorrhagia  and  menorrhagia  occurred ; 
then  subsequent  contraction  occurring  in  the  effused  lymph  in  and 
around  the  ovaries,  atrophy  resulted  with  its  usual  consequence, 
amenorrhoea. 

The  peculiarly  destructive  influence  exerted  upon  the  ovaries  l)y 
pelvic  peritonitis  will  be  impressed  upon  any  one  who  makes  an 
41 


642  DISEASES    OF    THE    OVARIES. 

autopsy  in  a  patient  who  has  died  of  that  atlection,  or  who  reads 
the  reports  of  others.  Very  often  the  ovaries  cannot  he  discovered 
in  the  mass  of  "putrilage"  which  occupies  their  site. 

Treatment. — An  attempt  may  be  made,  by  the  means  recom- 
mended in  the  treatment  of  undeveloped  ovaries,  to  excite  ovula- 
tion in  any  part  of  the  glands  which  may  still  be  capable  of  per- 
formino-  the  function.  But  it  should  not  be  persisted  in  if  not  at 
once  attended  by  good  results,  for  inflammatory  action  may  be 
excited  by  it.  When  these  means  are  essayed,  great  caution  should 
be  observed  and  their  influence  developed  only  to  a  limited  degree. 

Ovarian  Apoplexy. 

Defnition. — The  word  apoplexy  is  very  loosely  employed  in  refer- 
ence to  sanguineous  eflTusions  in  all  the  organs  of  the  body,  some 
signifying  by  it  sudden  vascular  rupture,  while  others  apply  it  to 
interstitial  hemorrhage  occurring  even  very  slowly.  This  has 
created  confusion  of  description,  and  certainly  added  difliculty  to 
the  clear  comprehension  of  the  pathological  states  to  which  it  has 
been  synonymously  applied.  Thus,  in  describing  ovarian  apoplexy, 
Kiwisch'  divides  it  into  primary  and  secondary,  considering  as 
examples  of  the  latter,  hemorrhage  from  the  walls  of  a  cyst  Avhich 
fills  it  slowly  with  blood,  or  hemorrhage  the  result  of  tapping. 
The  two  conditions  should  be  regarded  as  essentially  difterent,  and 
I  would  offer  this  as  the  proper  definition  of  our  subject.  Apoplexy 
of  the  ovary  consists  in  a  rapid  effusion  into  its  tissue  of  blood, 
which  results  from  rupture  of  one- or  more  of  its  larger  vessels. 

The  ovaries  present  the  only  example  in  the  animal  economy 
of  apoplexy  occurring  as  a  physiological  act.  At  each  menstrual 
period,  as  an  ovule  leaves  its  nidus,  an  apoplexy  from  the  vessels 
of  the  tunic  of  the  ovisac  occurs  as  a  necessary  consequence.  It 
is  this  which,  upon  subsequent  alteration,  constitutes  the  corpus 
luteum.  Generally  these  hemorrhages  are  self-limiting,  and  their 
effects  rapidly  disappear;  in  some  cases,  however,  the  bleeding 
continues  too  long  or  returns  after  cessation,  and  then  the  collec- 
tion of  blood  sometimes  reaches  the  size  of  a  man's  fist  or  of  a 
child's  head.^  In  some  instances  the  tunica  albuginea  of  the  ovary 
is  completely  ruptured,  when  the  effused  blood  pours  into  the  most 
dependent  portion  of  the  pelvic  cavity,  constituting  pelvic  hemar 
tocele. 

Symptoms. — The  occurrence  of  apoplexy  is  often  ascertained  only 

'  Op.  cit.,  p.  232.  2  Kiwisch,  op.  cit..  p.  232. 


DISPLACEMENT    OF    THE    OVARIES.  643 

in  autopsy,  no  signs  existing  during  life  by  which  it  can  be  posi- 
tively diagnosticated.  The  symptoms  which  w^ill  usually  point  to 
its  existence  are  sudden  and  violent  pain  over  the  region  of  one 
ovary,  with  sense  of  great  exhaustion,  nausea,  and  vomiting.  These 
symptoms,  if  combined  with  enlargement  and  tenderness  of  one 
ovary,  as  ascertained  by  conjoined  manipulation,  will  be  sufficient 
to  render  a  diagnosis  warrantable  if  the  patient's  health  has  pre- 
viously been  good. 

Prognosis. — The  great  danger  from  the  accident  is  j)eritonitis, 
arising  either  from  implication  of  the  peritoneal  fold  which  makes 
the  broad  ligament,  or  from  rupture  of  the  cortical  portion  of  the 
ovary  and  occurrence  of  hematocele. 

Treatment, — Should  there  be  symptoms  of  peritonitis,  leeches 
should  be  applied,  and  followed  by  poultices  or  a  blister.  Beyond 
this,  all  that  can  be  done  is  to  keep  the  patient  quiet  in  the  recum- 
bent posture,  and  prevent  all  muscular  effort  until  absorption  occurs. 

Displacement  of  the  Ovaries. 

The  extreme  mobility  of  these  glands  and  the  laxity  of  tlieir  sup- 
ports have  already  been  remarked  upon.  Any  influence  which 
increases  their  weight,  draws  upon  them  directlj^,  or  acts  upon 
them  by  traction  through  a  neighboring  organ,  may  cause  them  to 
leave  their  position,  and  even  in  rare  cases  to  pass  out  of  the  pelvis 
in  the  form  of  hernia.  For  example,  they  may  be  displaced  by 
inflammation,  hypertrophy,  ovarian  foetation,  etc.,  which  cause 
increase  of  weight;  or  they  may  be  acted  upon  by  contractions  of 
eftused  lymph,  resulting  from  pelvic  peritonitis  ;  contraction  of  the 
ovarian  ligaments,  etc.,  drawing  them  out  of  place;  or  they  maybe 
aftbcted  by  displacement  of  the  uterus,  pregnancy,  or  hernia  of  any 
of  the  abdominal  viscera  acting  upon  them  by  means  of  traction. 
A  hernia  of  the  ovary  alone  is  very  rare;  it  is  almost  always  attended 
by  hernia  of  the  Fallopian  tube,  or  some  portion  of  the  intestines 
or  omentum. 

The  ovaries  often  fall,  when  their  weight  is  increased,  into  the 
cul-de-sac  of  Douglas.  More  rarely  they  pass  into  tlie  inguinal 
canals,  or  through  them  into  the  dartoid  sacs  of  the  labia  majora. 
Here  they  show  a  monthly  intumescence,  which  creates  great  local 
disturbance,  and  keeps  the  part  swollen,  heated,  and  tender,  until 
ovulation  is  passed.  Deneux^  declares  that  they  may  enter  the 
femoral,  umbilical,  and  ischiatic  openings,  or  form  a  part  of  ventral 

'  Recherches  sur  la  Hernie  de  I'Ovaire. 


644  DISEASES    OF    THE    OVARIES. 

hernia,  and  Kiwisch  lias  reported  &  case  in  wtiicli  one  entered  tbe 
foramen  ovale.  The  accident  is  rarelj^  important  in  its  results 
except  in  reference  to  excluding  the  suspicion  of  other  forms  of 
tumor,  and  avoiding  the  danger  of  surgical  interference  under  a 
mistaken  diagnosis. 

Treatment. — The  treatment  consists  in  returning  the  displaced 
part  hy  taxis,  and  keeping  it  in  sitH  by  a  properly  constructed 
truss,  jiessary,  or  bandage.  Should  the  gland  be  bound  in  its  false 
position  by  strong  membranes,  tlie  propriety  of  its  removal  might 
be  considered,  in  case  serious  inconvenience  resulted  from  the  dis- 
placement. 

Ovaritis. 

Definition. — By  this  term  is  meant  an  inflammation  of  the  tissue 
comprising  the  ovaries,  •which  has  been  described  by  some  authors 
under  the  name  of  Oophoritis.  A  dogmatic  treatise  upon  ovaritis 
in  the  non-puerperal  woman  is,  in  the  present  state  of  science, 
impossible.  So  much  concerning  the  disease  is  unsettled,  and  such 
utterly  discordant  views  are  entertained  ujton  it  by  the  most  reliable 
authorities,  that  too  great  caution  cannot  be  observed  in  treating 
of  the  subject,  lest  theories  constructed  ujion  analogical  reasoning 
be  made  to  pass  current  in  the  mind  of  the  reader  for  facts  faith- 
fully observed  at  the  bedside  and  in  the  dead-house.  JSTo  writer 
should  attempt  its  descrijition  without  determining,  as  Aran  did, 
when  he  penned  the  following  sentence :  "  I  leave  out  of  considera- 
tion all  the  fantastic  descrijttions  of  ovaritis  which  have  been  con- 
structed in  the  library  by  physicians  who  were  more  remarkable 
for  brilliancy  of  imagination  than  knowledge  of  the  disease."  Our 
knowledge  of  the  subject  is  at  least  so  far  advanced  as  to  make  a 
theoretical  essay  upon  it  entirely  inadmissible. 

Varieties. — Ovaritis  may  be  either  puerperal  or  non-puerperal. 
The  first  does  not  concern  our  present  investigation,  and  we  [lut  it 
out  of  consideration.  The  non-puerperal  form  of  the  disease  has 
been  divided  into  acute  and  chronic,  which  will  now  engage  us  in 
order. 

Aeute  Ovaritis. 

This  affection,  though  very  common  as  a  result  of  parturition 
or  abortion,  is,  except  as  a  complication  of  pelvic  peritonitis  or 
cellulitis,  quite  rare  in  the  non-puerperal  woman.  Mme.  Boivin' 
even  goes  so  far  as  to  say  that,  "it  would  be  diflftcult  to  point  to  a 

'  Op.  cit. 


ACUTE    OVARITIS.  645 

single  well-authenticated  case  out  of  the  condition  of  preo-nancy." 
Dr.  West^  remarks  that,  "acute  inflammation  of  the  substance  of 
the  unimpregnated  ovary  is  of  such  rare  occurrence  that  no  case 
has  come  under  my  own  care,  and  but  one  has  presented  itself  to 
my  observation."     Prof.  Fordyce  Barker^  says,  "I  doubt  very  much 
if  I  have  ever  seen  a  clear,  well-marked  case,  and  I  have  been  for 
years  looking  for  its  existence  in  the  dead-house."     There  can  be  no 
question  of  the  truth  of  these  statements  as  regards  pure,  uncom- 
plicated inflammation  of  the  ovary,  but  ovaritis  of  acute  character 
going  on  to  suppuration  or  production  of  a  ditiSiuent  state  of  the 
stroma,  is  by  no  means  rare  as  a  complication  of  pelvic  cellulitis 
or  peritonitis.     One  of  the  greatest  dangers  to  be  feared  from  these 
diseases  is  injury  or  destruction  of  the  ovaries,  and  it  is  probable 
that  few  cases  of  cellulitis  and  none  of  peritonitis  run  their  course 
without  involving  them  to  a  greater  or  less  extent.     It  is  likewise 
probable  that  pelvic  peritonitis  is  frequently  excited  by  some  trouble 
originating  in  the  ovaries,  which  are  closely  in  contact  with  the 
peritoneum  making  up  the  broad  ligaments  and  covering  the  pelvic 
roof.     The  intimate  relation  of  these  parts,  the  ovaries,  the  pelvic 
peritoneum,  and  the  pelvic  areolar  tissue,  accounts  for  the  fact  that 
uncomplicated  acute  ovaritis  is  rarely  met  with. 

In  proof  of  this  statement  let  me  point  to  the  condition  of  the 
ovaries  in  the  autopsies  of  periuterine  cellulitis  reported  by  Aran. 
In  almost  all  instances  they  were  diseased,  and  they  generally  con- 
tained pus.  So  common  was  this  lesion  that  Aran  was  persuaded 
that  "  the  purulent  collections  which,  as  a  consequence  of  peri- 
uterine inflammation,  discharge  themselves  into  the  peritoneum  or 
into  the  organs  in  the  neighborhood  of  which  they  are  placed, 
rectum,  bladder,  vagina,  etc.,  sometimes  even  by  the  surface,  belong 
more  particularly  to  the  ovary  or  tube." 

Since  the  writings  of  Aran,  no  one  has  done  more  to  put  in  a 
strong  and  proper  light,  the  intimate  relations  existing  between 
inflammation  of  the  ovaries,  suppuration,  and  pelvic  peritonitis  and 
cellulitis,  than  Dr.  Matthews  Duncan.  He  regards  these  periuterine 
inflammations  as  always  symptomatic  affections ;  as  secondary  to 
uterine,  tubal,  or  ovarian  disease,  or  noxious  discharges  entering 
the  peritoneal  cavity  through  the  tubes.  At  the  same  time  that  I 
difter  from  Dr.  Duncan,  in  looking  upon  periuterine  inflammation 
as  more  frequently  primary  than  he  considers  it,  and  as  commonly 


'  Op.  cit.,  p.  473.  2  Bui.  N.  Y.  Acad.  Med.  vol.  i,  p.  549. 


646  DISEASES    OF    THE    OVARIES. 

resulting  in  acute  or  chronic  ovaritis  and  abscess,  I  admit  that  the 
sequence  of  events  is  often  that  which  he  states. 

Authors  have  divided  acute  ovaritis  into  parenchymatous,  fol- 
licular, and  peritoneal,  but  in  an  affection,  the  mere  recognition  of 
which  is  so  difficult,  it  is  hardly  wise  to  refine  upon  its  peculiarities. 
The  form  of  the  affection  styled  peritoneal  is  really  not  ovaritis, 
but  peritonitis  of  the  very  character  of  which  we  are  speaking ; 
from  which  to  parenchymatous  and  follicular  disease  there  is  only 
one  step.  As  an  example  of  ovaritis  complicated  with  peritonitis 
in  a  non-pregnant  woman,  I  avail  myself  of  the  kindness  of  Dr. 
Roth,  and  record  the  following  history  prepared  by  him. 

"M.  S.,  set.  35,  married  ten  years,  had  a  miscarriage  nine  years 
ago.  Since  that  time  has  suffered  from  dysmenorrhoea  and  gastric 
disorder,  which  was  styled  dyspepsia.  Two  years  ago  she  applied 
to  me,  and  I  found  her  suffering  from  profuse  fluor  albus  and  retro- 
flexion of  the  womb.  Under  use  of  caustics  and  tonics  she  improved 
very  much,  and  treatment  was  stopped.  I  did  not  see  her  again 
until  August  1st,  1866,  when  I  found  her  in  a  convulsion.  After  it 
had  passed  oft'  she  vomited  constantly,  complained  of  great  pain  in 
the  bowels,  was  very  thirsty,  and  the  pulse  was  near  a  hundred. 
Opium  was  freely  administered.  On  the  next  day  the  pulse  was 
over  one  hundred;  skin  hot  and  dry;  and  she  complained  of  severe 
pain  in  back  and  loins,  and  over  left  iliac  fossa.  I  made  a  vaginal 
examination  by  touch,  but  could  discover  nothing  except  that  the 
vagina  was  very  hot  and  dry.  Aug.  3.  l^o  great  change,  except 
that  the  abdomen  became  tympanitic.  Aug.  4.  She  lost  about  five 
ounces  of  blood  per  vaginam;  symptoms  unchanged.  Aug.  6.  She 
was  seen  in  consultation  by  Prof.  Thomas,  who  diagnosticated  pel- 
vic peritonitis  with  probable  acute  ovaritis  on  left  side,  and  antici- 
pated formation  of  an  abscess  near  or  in  the  ovary.  By  his  advice 
a  large  blister  was  ap[»lied  over  the  hypogastrium,  and  opium  given 
in  very  large  doses.  The  case  went  on  in  this  way  until  Aug.  11th, 
when  she  suddenly  vomited  a  large  amount  of  bile,  became  col- 
lapsed, and  died  that  night. 

"  Autopsy  eighteen  hours  after  death. — Tlie  peritoneum  covering 
the  pelvic  viscera  was  covered  with  a  recent  lymph,  and  between 
the  organs  a  great  deal  of  puriform  serum  existed.  Abdominal 
peritoneum  healthy.  The  left  ovary,  which  was  agglutinated  to  the 
intestines,  tube,  and  uterus,  was  about  the  size  of  a  hen's  egg.  In 
its  removal  it  was  broken,  and  several  ounces  of  pure  pus  escaped. 
No  evidences  of  cellulitis  could  be  discovered  upon  careful  dissec- 
tion.    Other  organs  healthy." 


ACUTE    OVARITIS.  647 

Pathology. — This  is  not  clearly  made  out,  though  it  appears  safe 
to  accept  the  stages  descrihed  by  Mine.  Boivin :  first  stage,  con- 
gestion, with  increase  of  weight  and  rotundity  ;  second  stage,  the 
organ  double,  triple,  or  quadruple  its  normal  size,  tissue  soft  and 
infiltrated  with  yellow  and  violet-colored  serum,  with  sliglit  eti'u- 
sion  of  blood ;  third  stage,  suppuration,  pus  infiltrated  or  collected 
in  spots ;  fourth  stage,  gray  softening,  disorganization,  the  gland 
becoming  difBuent. 

Causes. — The  causes  of  the  disease  may  be  thus  enumerated : 

Pelvic  peritonitis ; 
Periuterine  cellulitis ; 
Gonorrhoea ; 
Disturbance  of  menstruation. 

Any  of  the  causes  which  have  been  spoken  of  as  sufficient  to 
cause  the  first  two  diseases  mentioned  may  through  them  produce 
ovaritis.  A  form  of  ovaritis  called  blennorrhagic  is  admitted  by 
most  authors  as  corresponding  with  blennorrhagic  orchitis  in  the 
male.  It  is  difiScult  to  see  how  even  the  progress  of  gonorrhoeal 
inflammation  along  the  tubes  would  cause  disease  of  an  organ  not 
connected  with  the  extremities  of  these  tubes,  but  let  it  be  remem- 
bered that  gonorrhoea  is  in  this  way  one  of  the  most  fruitful 
sources  of  pelvic  peritonitis,  and  an  explanation  of  ovaritis  as  a 
secondary  result  will  suggest  itself.  Suppression  of  menstruation, 
or  any  sudden  and  violent  shock  given  to  the  ovaries  while  ovu- 
lation is  progressing  and  the  walls  of  the  organ  are  about  being 
broken  through,  may  likewise  induce  it. 

Symptoms. — The  symptoms  of  this  affection  are  so  intimately 
associated  with  those  of  peritonitis  and  cellulitis  that  it  is  impos- 
sible to  separate  them.  There  is  severe  pain  in  one  or  other  iliac 
fossa,  with  increase  of  heat,  fever,  and  perhaps  chill.  Pressure 
shows  the  most  exquisite  sensitiveness,  and  when  the  part  is 
examined  by  conjoined  manipulation  this  is  excessive.  By  that 
means  the  ovary  is  felt  enlarged  and  generally  depressed  in  the 
pelvis.  These  symptoms  may  subside  upon  the  occurrence  of 
resolution  in  four  or  five  days  ;  or  pus  forming  within  the  gland 
may  be  discharged  into  the  peritoneum,  the  rectum,  the  vagina,  or 
the  bladder. 

Differ e7itiation. — This  is  generally  impossible.  The  association 
of  the  disease  with  those  which  have  been  mentioned  as  being  at 
times  its  causes,  at  others  its  consequences,  is  usually  too  intimate 
for  its  distinction  from  them.     Should  conjoined  manipulation  dis- 


648  DISEASES    OF    THE    OVARIES. 

cover  tlie  ovarj  as  a  round  ball,  very  sensitive,  and  unassociated 
with  fixation  of  the  uterus,  a  diagnosis  would  be  admissible.  I 
have  never  met  with  such  a  case  of  acute  character,  nor  is  it 
likely  that  it  often  occurs,  though  in  subacute  or  chronic  ovaritis 
these  physical  signs  are  common. 

Prognosis. — The  prognosis  is  favorable,  though  never  free  from 
an  element  of  doubt. 

Treatment. — Leeches  may  be  applied  around  the  anus,  over  the 
diseased  organ,  or  at  the  groin.  Should  its^  weight  not  give  [)ain, 
a  poultice  should  then  be  placed  over  thehypogastrium,  and  oi)ium 
freely  .administered  by  mouth  or  rectum.  The  patient  should  be 
kept  perfectly  quiet,  and  not  allowed  to  rise  from  her  bed  even  for 
relief  to  the  calls  of  nature.  Especial  care  in  this  regard  should  be 
observed  if  it  be  supposed  that  suppuration  has  occurred,  for  then 
a  very  slight  effort  might  cause  a  rupture  of  the  abscess  into  the 
peritoneum. 

Chronic  Ovaritis. 

Chronic  inflammation  of  the  ovaries  is  an  aifection  of  common 
occurrence,  though  very  little  has  been  ascertained  as  to  the  ex- 
act frequency  of  the  disease.  So  great  is  the  symjtathy  existing 
betwpen  the  uterus  and  these  organs,  that  uterine  disorders  excite 
ovarian  pain  very  commonly,  and  give  rise  to  many  symptoms 
which  are  regarded  as  characteristic  of  this  disease.  Again,  it  is 
a  well-ascertained  fact  that  slight  attacks  of  chronic  pelvic  peri- 
tonitis are  extremely  common,  and  unfortunately  we  possess  no 
certain  means  for  distinguishing  such  a  disorder,  in  the  vicinity 
of  an  ovary,  from  chronic  ovaritis. 

In  the  great  majority  of  cases  of  uterine  disease  the  patient  will 
complain  of  pain,  of  dull  aching  character,  over  one  or  both  ovaries, 
and  this  will  very  likely  be  augmented  by  menstruation.  But  it 
is  by  no  means  to  be  concluded  that  this  sympathetic  pain,  even  if 
dependent,  as  it  very  often  is,  uy)on  congestion,  is  due  to  chronic 
ovaritis.  As  well  might  it  be  believed  that  mammary  pains  ex- 
cited in  the  same  manner  are  due  to  mammitis. 

As  a  primary  affection  which  creates  secondary  uterine  disorder 
and  results  in  dysmenorrhoea,  sterility,  and  hysteria,  it  is  by  no  means 
rare.  Many  cases  supposed  to  be  obscure  and  unmanageable  ones 
of  uterine  disorder,  many  in  which  the  physician  is  sorely  puzzled 
in  accounting  for  the  wonderful  disproportion  between  the  existing 
symptoms  and  the  degree  of  uterine  disorder  discoverable,  are  due 
to  this  affection.     Instances  will  not  rarely  be  met  with  in  which 


CHKONIC    OVARITIS.  649 

with  slight  uterine  displacement,  and  a  catarrh  of  no  great  moment, 
a  patient  will  be  entirely  unable  to  stand  or  walk  except  for  very 
short  periods  of  time,  will  for  years  prove  sterile,  and  will  suft'er 
from  agonizing  dysmenorrhoea  from  this  cause.  The  revival  of 
uterine  pathology  has  drawn  oif  attention  too  completely  from  the 
ovaries.  The  coming  decennium  will,  I  feel  convinced,  prove  that 
in  many  cases  disease  of  these  most  important  organs  in  the  female 
economy  is  the  source  of  many  ills  now  attributed  to  that  less  im- 
[lortant  viscus  the  uterus.  It  is  in  the  study  of  ovarian,  not  uterine, 
pathology,  that  the  next  great  advances  in  gynecology  are  to  be 
made. 

Symjjtoms. — The  symptoms  of  chronic  ovaritis  are  numerous  and 
often  perplexing  ;  no  two  cases  of  the  affection  presenting  the  same 
features.  In  some  they  are  physical  entirely,  while  in  others  the 
mind  and  nervous  system  are  decidedly  involved.  In  two  cases  in 
my  experience  true  epilepsy  has  existed,  whether  as  a  consequence 
or  not  I  cannot  say,  but  certainly  as  a  very  suspicious  complica- 
tion. 

The  rational  signs  may  be  enumerated  as — 

Dysmenorrhoea ; 

Fixed  pain  over  one  or  both  ovaries ; 

Tendency  to  hysteria; 

Rarely  inability  to  stand  or  walk ; 

Sometimes  pain  on  sexual  intercourse; 

Pain  and  exhaustion  after  defecation ; 

Pain  in  rectum  and  down  thighs; 

Irregular  menstruation; 

Frequently  leucorrhoea; 

Sterility  if  both  ovaries  are  diseased. 

Dysmenorrhoea  often  precedes  menstruation  by  several  days.  At 
ther  times  it  occurs  just  after  the  cessation  of  the  menstrual  dis- 
harge ;  while  in  a  few  cases  it  occurs  in  the  interval  between  the 
lenstrual  periods.  The  last  constitutes  the  intermediate  dysmen- 
rrhcea  of  Dr.  Priestly,  and  is  a  most  interesting  symptom.  At 
mes  it  occurs  with  great  regularity.  In  one  case  which  occurred 
1  my  practice  it  showed  itself  invariably  on  the  ninth  day,  and  in 
lother  on  the  fourteenth.     Ovarian  dysmenorrhoea  produces  great 

"rvous  disturbance,  which  renders  the  patient  peculiarly  prone  to 

ek  relief  in  the  use  of  opium. 

Within  the  past  two  years  I  have  met  with  three  cases  of  this 


650  DISEASES    OF    THE    OVARIES. 

disease  in  wliicli  tlie  patients  have  been  unable  to  stand  or  walk, 
except  for  a  few  minutes.  Two  of  them  are  now  under  my  care, 
and  are  almost  bedridden. 

If  the  ovary  be  prolapsed,  sexual  intercourse  often  proves  a  source 
of  pain,  but  not  otherwise. 

The  menstrual  discliarge  is  sometimes  very  irregular,  remaining 
absent  for  months,  and  then  showing  itself  as  an  alarming  hemor- 
rhage. In  many  cases  it  is  quite  regular  both  as  to  time  of  occur- 
rence and  amount. 

The  continued  uterine  irritation  kept  up  by  chronic  ovaritis  often 
engenders  uterine  catarrh,  which  proves,  in  consequence  of  its  cause, 
very  intractable  to  treatment. 

That  in  many  cases  the  patients  become  pregnant  cannot  be 
questioned,  but,  as  a  rule,  where  both  ovaries  are  diseased  sterility 
exists.  It  is  highly  probable  that  the  diseased  organs  produce  dis- 
eased or  imperfect  ova. 

Physical  Signs. — The  patient  being  examined  by  touch  and  con- 
joined manipulation  the  uterus  will,  for  some  reason  which  I  can- 
not appreciate,  be  usually  found  to  deviate  from  its  normal  axis,  , 
laterally,  anteriorly,  or  posteriorly,  and  from  the  cervical  canal  a  i 
thick  mucous  plug  will  often  be  found  to  hang.     In  Douglas's  cul- 
de-sac,  or  on  one  or  on  each  side  of  the  uterus,  a  round,  soft,  tender 
body,  about  as  large  as  a  walnut,  will  be  found.    This,  when  caught 
between  the  fingers,  in  conjoined  manipulation,  will  prove  very 
sensitive  to  pressure,  which  will  often  produce  nausea  and  tendency  J 
to  hysteria ;  and  even  after  it  has  been  desisted  from,  a  dull  aching  i 
pain  will  generally  remain.  j 

Prognosis. — I  know  of  few  curable  disorders  which  I  dread  so  i 
much  to  meet  as  this.  The  day  will  probably  come  when  our 
treatment  for  it  will  be  satisfactory  and  efiicient,  but  it  has  not  yet  • 
done  so  by  any  means.  Many  cases  will  entirely  baffle  treatment,  i 
while  all  will  prove  little  amenable  to  it.  That  they  in  time  i 
recover  is  true,  but  recoveries  have,  in  my  experience,  but  little 
connection  with  treatment. 

Treatment— 1  have  nothing  better  to  offer  than  the  following  . 
course,  the  meagreness  of  which  I  regret.  If  the  ovaries  be  found 
prolapsed  they  should  be  carefully  sustained  by  a  light  elastic  ring 
pessary,  and  if  the  displaced  uterus  press  upon  them  it  should  be 
kept  in  position.  Sexual  intercourse  should  be  limited  as  far 
as  possible.  If  scanty  menstruation  exist  as  a  symptom,  one  or 
two   leeches  should  be  applied  every  month  to  the  cervix  uteri. 


OVARIAN    TUMORS.  651 

Rest  sliould  be  prescribed  during  menstrual  epochs,  when  the  dis- 
eased gkmds  are  congested  and  in  a  state  of  nervous  excitement,. 
Severe  exercise  or  fatiguing  occupations  should  be  avoided,  and  all 
influences  calculated  to  depress  the  vital  forces  carefully  guarded 
against.  Counter-irritation  by  means  of  small  blisters,  tincture  of 
iodine,  or  issues  of  nitric  acid,  should  be  kept  up  over  the  diseased 
organs  for  months  at  a  time,  and  once  or  twice  a  week  the  cervix 
uteri  and  whole  upper  part  of  the  vagina  should  be  painted  over 
with  tincture  of  iodine.  Every  night  and  morning  the  patient 
should  be  directed  to  use  copious  injections  of  warm  water  into 
the  vagina  in  the  manner  elsewhere  explained.  For  the  various 
nervous  symptoms  which  accompany  the  affection  the  bromide  of 
potassium  in  ten  to  fifteen  grain  doses  will  be  found  very  beneficial. 
Utero-gestation,  which  secures  the  ovaries  from  monthly  conges- 
tions for  nine  months,  is  always  much  to  be  desired  under  these 
circumstances. 


CHAPTER    XLIV. 


OVARIAN  TUMORS. 


Within  the  last  twenty  years  important  advances  have  been 
made  in  our  knowledge  of  those  pathological  developments  called 
tumors.  The  progress,  which  about  the  beginning  of  that  period 
Kokitansky  inaugurated,  has  since  culminated  in  the  eminent  labors 
(of  Virchow.  Had  we  now  reached  a  standpoint  which  gave  com- 
iplete  satisfaction  to  pathologists,  it  would  be  an  easy  matter  to 
(offer  a  simple  digest  of  the  whole  subject  for  the  contemplation  of 
ithe  student.  But  this  is  far  from  being  the  present  aspect  of  the 
isubject.  Changes  are  constantly  being  made  in  nomenclature; 
■views  as  to  pathology  are  daily  being  altered;  and  classification  is 
in  consequence  undergoing  frequent  alterations.  This  presents 
^evident  difficulties  for  one  who,  not  being  entitled  by  personal  re- 
fsearches  to  original  views,  is  forced  to  rely  upon  the  workers  in 
)athological  anatomy  for  his  authority.  Every  one  who  has  really 
tudied  the  subject  of  tumors  will  admit  the  force  of  this  state- 
uent  and  from  such  an  one  I  have  no  fears  of  a  severe  judgment 


652 


OVARIAN    TUMORS. 


upon  the  table  by  which  I  here  endeavor  to  display  at  a  glance  the 
varieties  of  ovarian  tumors.  I  am  fully  aware  of  its  imperfections, 
but  I  know  of  no  better  method  for  simplifying  a  difficult  subject 
so  as  to  make  it  easily  comprehensible  to  the  general  reader,  and 
none  which  will  prove  so  useful  in  clinical  investigation. 

For  the  purpose  of  facilitating  the  clinical  study  of  ovarian 
tumors,  it  is  probably  best  to  consider  them  under  two  heads:  first, 
those  which  are  solid  and  free  from  cystic  development;  second, 
those  which  are  characterized  by  such  development. 

The  following  table  presents  at  a  glance  these  genera  and  those 
of  their  species  which  are  met  with  at  the  bedside,  not  as  patho- 
logical curiosities,  but  as  diseased  conditions  requiring  surgical 
interference.  Certain  forms  which  are  rarely  met  with,  even  by 
the  most  industrious  morbid  anatomists,  will  receive  casual  mention, 
but  I  cannot  believe  that  good  arises  from  blending  these  in 
description  with  others  whieli  are  constantly  presenting  themselves 
to  the  attention  of  the  practitioner. 


Ovarian 
tumors 


Solid  tumors 


Cystic  tumors 


I 


Pelvic  cysts  closely  resembling  j 
ovarian 


Carcinoma ; 
Fibroma. 

Cysto-carcinoma ; 
Cysto-fibroma  or  sarcoma ; 
Dermoid  cysts; 
'Ovarian  cysts  and  cystomata. 

Cysts  of  broad  ligaments  ; 
Parasitic  cysts ; 

Hydro-salpinx ;  I 

Uterine  cysts  and  fibro-cysts ; 
Encysted  peritoneal  dropsy; 
Subperitoneal  cysts;  '        '. 

Cysts  connected  with  the  spinal 
cord. 

Under  the  head  of  solid  tumors,  enchondroma  and  osteoma  have' 
been  reported,  but  the  authenticity  of  the  fcAV  cases  noted  is  very; 
doubtful.  Under  that  of  cystic  tumors  might  be  mentioned  hydrops 
folliculorum,  which  sometimes  creates  a  sac  as  large  as  a  child's' 
head,  and  Rindfleisch  describes  a  rare  form  of  cysto-colloid  degene-' 
ration  of  both  ovaries  growing  larger  than  a  man's  fist,  to  which 

'  A  cyst  is  a  collection  of  fluid  developed  within  a  pre-existing  sac ;  a  cystoma 
one  which  creates  its  own  sac. 


CAECINOMA.  653 

he  applies  the  name  of  striiina  ovarii.  These  affections,  of  threat 
interest  to  the  pathologist,  I  have  not  thouglit  it  best  tc  classify 
with  the  more  frequent  forms  of  ovarian  disease  which  commonly 
call,  not  for  diagnosis  merely,  but  for  surgical  interference,  for  fear 
of  uselessl}^  complicating  the  already  ditHeult  subject  of  diugnosis. 
Carcinoma. — -The  ovary  may  be  affected  by  several  varieties  of 
cancerous  deposit,  which  are  here  placed  before  the  reader  : 

1.  It  may  be  affected  by  true  scirrhous  degeneration.  This 
form  of  cancer  is  less  common  than  others,  occurs  usually  after 
middle  life,  and  may  create  a  tumor  of  large  dimensions.  It 
develops  slowly,  and  presents  the  physical  appearance  of  scir- 
rhous disease  in  other  organs ;  it  may  be  a  primary  malignant 
development;  or  it  may  occur  in  the  ovary  secondarily,  its  primary 
development  having  been  previously  recognized  in  some  other  part 
of  the  system. 

2.  The  ovary  may  be  the  seat  of  medullary  cancerous  deposit, 
■which  may  originatedn  the  vesicles  of  DeGraaf ;  in  a  corpus  luteum, 
as  Rokitansky  once  saw  it  do;  or  in  the  stroma  of  the  organ.  Dis- 
tention sometimes  causes  rupture  of  the  tunica  albuginea  of  the 
ovary,  and  then  exuberant  medullary  gi'owth  develops  in  contact 
with  the  peritoneum  and  abdominal  viscera. 

3.  Scirrhous  or  medullary  cancer  may  alone  or  united  attack 
the  wall  of  a  cyst,  and  develop  either  as  an  endogenous  or  exo- 
genous production.  The  cancerous  matter  so  completely  invades 
the  cyst-walls  in  some  cases  as  to  make  it  appear  that  cystic  de- 
generation had  occurred  secondarily  to  its  deposit. 

4.  From  the  wall  of  a  cyst,  vascular,  arborescent  villi  may  pro- 
ject, lining  the  cavity,  and,  in  time,  filling  and  distending  it  so 
as  to  cause  the  rupture  of  its  walls.  Then  the  exuberant  cancer- 
ous element  develops  in  innnediate  contact  with  the  peritoneum, 
and  produces  either  a  dangerous  peritonitis  or  abundant  abdominal 
dropsy. 

With  this  form  of  cancer  colloid  degeneration  is  often  associated, 
when  it  constitutes  that  variety  which  has  been  described  by  Cru- 
veilhier  as  alveolar  cancer. 

The  recognition  of  the  fact  that  the  ovarian  disease  which  affects 
a  patient  partakes  of  the  character  of  anj'  one  of  the  forms  of  can- 
cer just  enumerated,  must  ever  be  a  matter  of  great  moment,  for 
upon  it  must  depend  not  o\\\y  our  prognosis,  but  in  some  cases  the 
determination  to  adopt  or  reject  the  operation  of  ovariotomy.  Even 
if  the  case  bo  one  of  malignant  disease,  however,  operative  pro- 
cedure may  accomplish  good  by  prolongation  of  life 


654  OVARIAN    TUMORS. 

The  symptoms  wliicli  generally  point  to  the  malignant  character 
of  an  ovarian  tumor  are  these : 

1.  The  raj)id  development  of  a  solid  tumor  in  an  ovary,  with — 

2.  Marked  depreciation  of  the  strengtli,  vital  forces,  spirits,  and 
general  condition  of  the  patient. 

3.  The  occurrence  of  oedema  pedum  and  spansemia  with  a  small 
tumor,  which  are  consequently  dependent  upon  a  general  blood 
state,  and  not  the  results  of  pressure  by  the  tumor. 

4.  Lancinating  and  burning  pains  through  the  tumor. 

5.  Cachectic  appearance. 

6.  The  occurrence  of  ascites  without  evidences  of  cirrhosis  or 
other  hepatic  disease,  organic  disease  of  the  kidneys,  or  heart,  or 
chronic  peritonitis. 

Cystic  degeneration  of  the  ovary  sometimes  advances  with  great 
rapidity,  and  is  accompanied  in  its  course  by  rapid  emaciation, 
marked  physical  prostration,  ascites,  and  a  cachectic  appearance. 
It  may  be  asked  whether  a  case  thus  complicated  would  not  pre- 
sent the  very  conditions  which  have  been  pointed  out  as  furnishing 
grounds  for  the  diagnosis  of  malignant  disease.  Unquestional)ly 
it  would.  Let  it  be  remembered  that  while  these  symptoms  are 
mentioned  as  valuable  aids  to  diagnosis,  I  do  not  pretend  to  main- 
tain that  they  will  always  enable  the  diagnostician  to  avoid  error. 
Again,  in  citing  ascites  with  a  solid  tumor  as  a  most  important 
symptom  of  malignant  ovarian  disease,  I  do  not  allude  to  slight  or 
even  moderate  effusion  with  a  large  growth,  but  a  markedly  dis- 
proportionate amount  of  fluid,  a  great  deal  of  abdominal  effusion 
with  a  very  small  tumor. 

Besides  the  condition  just  mentioned  there  are  two  others  which 
may  create  difficulty  in  differentiation  from  ovarian  cancer ;  one 
is  pregnancy  in  the  middle  or  latter  months,  complicated  by  peri- 
toneal effusion;  the  other,  a  uterine  fibroid  existing  with  attendant 
dropsy.  The  first  may  generally  be  known  by  its  characteristic 
symptoms :  while  the  second,  although  it  might  be  recognized  by 
the  physical  and  rational  signs  of  uterine  fibroids,  would  very 
likely  give  considerable  trouble  in  diagnosis. 

When  difficult  and  obscure  cases  present  themselves  in  which  i 
a  positive  diagnosis  becomes  impossible  by  ordinary  means,  p»arar- 
centesis,  explorative  incision,  or  both,  should  be  resorted  to  rather 
than  that  the  patient  should  be  deprived  of  the  prospect  for  cui-e 
held  out  to  her  by  ovariotomy.  Very  often  the  most  doubtful  case 
may  be  satisfactorily  settled  b}'^  evacuating  the  abdominal  effusion, 
and  passing  the  index  finger  through  a  small  opening  in  the  peri- 


FIBROMA,    OR    FIBROUS    TUMOR.  655 

roneum  so  as  to  touch  the  morbid  growth.     In  certain  rare  cases 
even  this  woukl  not  suffice  to  remove  all  douht. 

By  these  means  I  have  succeeded  in  making  a  correct  diao-nosis 
in  several  cases  of  true  ovarian  cancer,  hut  in  relying  upon  tbem 
I  have  twice  failed  entirely,  pronouncing  as  cancer  Avhat  afterwards 
t  urned  out  to  be  benign  growths.  Cystic  ovarian  tumors  may  un- 
(juestionably  produce  excessive  ascites  and  all  of  the  other  rational 
signs  which  I  have  here  recorded  as  evidences  of  cancer. 

Fibroma^  or  Fibrous  Tumor. — This  form  of  tumor  is  rarely  met 
A^ith  in  the  ovary,  and  never  attains  a  very  great  size.  Kiwisch 
reports  two  cases,  one  the  size  of  a  child's,  and  the  other  the  size 
•  if  a  small  adult  head.  Dr.  Farre  discredits  the  reports  of  large 
ovarian  fibroids  which  are  upon  record,  and  believes  them  to  have 
l.een  in  reality  either  cancerous  tumors  or  growths  connected  with 
rlie  uterus,  which  so  encroached  upon  the  ovaries  as  to  seem  to 
have  si)rung  from  them.  Periuterine  fibroids  which  spring,  not 
from  the  uterus  itself,  but  from  the  extension  of  uterine  fibres  into 
the  broad  and  utero-sacral  ligaments,  have  probably  often  given  rise 
to  errors  in  reports  of  such  tumors.  Many  of  the  reported  cases 
of  ovarian  fibroids  have  likewise  been  due  to  confusion  of  this 
form  of  tumor  with  cysto-fibroma.  When  the  disease  does  afi:cct 
the  ovary  it  difi:ers  in  no  essential  degree  from  the  same  affection 
of  the  uterus,  except  that  pediculation  does  not  occur  as  in  the 
latter  organ,  and  that  the  growth  of  the  tumor  is  much  more.' 
limited. 

The  reader  must  be  reminded  that  these  remarks  api»ly  to  the 
pure  fibroid  and  not  the  fibro-cystic  ovarian  tumor,  wliicli  may 
attain  an  immense  size,  and  is  ahvays  to  be  regarded  as  a  serious 
disease.  Tliey  likewise  apply  to  the  development  of  fibroid  tissue 
into  true  fibromata,  for  in  the  walls  of  cystic  and  cystomatous 
growths  fibroid  tissue  is  commonlj^  developed. 

Virchow  believes  that  of  the  well  authenticated  cases  of  true 
ovarian  fibroma,  the  size  has  varied  between  that  of  a  hen's  eg^ 
and  that  of  a  child's  head.  Larger  ones  he  regards  as  cases  of 
cysto-fibroma.  Foerster  reports,  however,  one  case  as  large  as  a 
man's  head ;  and  Scanzoni  and  Van  Buren  similar  ones.  Dr. 
Peaslee'  records  a  case  of  this  size  removed  by  nie  in  18G4,  but  I 
cannot  agree  in  his  classification.  It  was,  according  to  my  vIcav, 
1  true  cysto-fibroma.  The  following  was  the  report  of  it  published 
icon  after  its  removal :  "  The  tumor,  when  placed  upon  a  table  and 


Op.  cit.,  p.  26. 


656  OVARIAN    TUMORS. 

palpated,  was  so  decei3tive  in  its  apparent  yielding  of  fluctuation, 
that  it  was  even  then  declared  to  contain  fluid  wliicli  had  not  been 
reached  by  the  trocar,  and  tliis  view  was  entertained  until  it  was 
bisected.  It  was  found  that  it  consisted  of  loose  fibrous  elements, 
forming  numerus  loculi,  about  the  size  of  a  hickory-nut,  which 
were  filled  with  a  honey-like  material.  After  section  had  allowed 
what  was  computed  as  about  three  jwunds  of  this  material  to  flow 
away,  the  tumor  weighed  a  little  more  than  fourteen  pounds." 

If  in  one  of  the  solid  tumors  just  mentioned,  cysts  develop  them- 
selves as  essential  j)arts  of  the  growths,  we  give  them  the  names 
of  cysto-fibroma,  cysto-sarcoraa,  or  cysto-carcinoma. 

Cysto-carcivoma. — The  formation  of  fluid  collections  may  occur 
with  cancer  of  the  ovary  in  three  ways:  1st,  cysts  may  develop  in 
the  structure  of  scirrhous  and  medullary  cancers,  as  they  do  in  that 
of  sarcomata;  2d,  a  fluid  or  cystic  tumor,  primitively  benign,  may 
develop  malignant  material  in  its  cyst-wall;  3d,  a  large  medullary 
cancer  may,  by  cell  infiltration  and  disintegration  at  its  centre, 
form  within  itself  a  mass  of  fluid.  The  condition  may  consist  then 
in  cancer  complicating  cystic  degeneration  or  in  cystic  degeneration 
complicating  cancer.  According  to  Scanzoni,  the  cancerous  mass 
may  develop  in  the  tissue  of  the  cyst-walls  and  project  either 
internally  or  externally,  or  it  may  grow  from  the  walls  by  pedicu- 
lated  or  sessile  tumors  filled  with  medullary  material,  which  are 
soft,  tumefied,  and  very  vascular.  In  the  same  tumor  both  colloid 
degeneration  and  medullary  cancer  may  be  met  with. 

The  ovarian  limits  do  not  always  confine  these  fatal  growths. 
At  times  they  pass  them,  and  atiect  the  peritoneum  or  other  neigh- 
boring parts.  This  tendency  to  eccentric  development  accounts  for 
the  protuberances,  the  size  of  the  fist,  so  often  serving  as  a  means 
of  diagnosis  of  ovarian  cancer.  The  distinguishing  characteristic 
of  cystic  cancer  is  its  rapidity  of  development.  In  a  few  months 
it  often  reaches  a  size  which  sarcoma  or  even  cystic  degeneration 
would  not  attain  for  several  years. 

The  frequency  of  these  and  other  ovarian  tumors  may  be  judged 
of  from  reference  to  some  statistics  accumulated  by  Scanzoni,  which 
have  been  already  referred  to: 

Number  of  cases  examined, 1823 

ovarian  tumors  among  them,  .....  97 

"             cases  submitted  to  autopsy,     .....  41 

"            fluid  tumors, 25 

"            colloid  tumors.        .......  9 

"            cysto-sarcomata, ,         .  5 

"             cystic  cancers, 2 


CYSTO-FIBROMA    OE    C  YSTO-S  AR  CO  M  A.  657 

From  this  it  will  be  seen  that  the  affection  which  we  are  now 
c(nisidering  is  rarer  than  sarcoma  and  very  much  rarer  than  colloid 
or  alveolar  degeneration. 

Surgical  treatment  holds  out  little  hope  in  these  cases.  According 
to  my  experience,  ovariotomy  performed  upon  patients  thus  affected 
almost  invariably  produces  death.  Nevertheless,  even  as  a  forlorn 
hope,  its  propriety  should  be  considered. 

The  prognosis  in  this  disease  is  graver  and  the  limit  of  life  shorter 
than  in  any  other  affection  of  the  ovaries. 

Cysto-jjhroma  or  Ci/s(o-sa7'coma.~~Bet\yeen  sarcoma  and  fibroma  of 
the  uterus  a  very  broad  distinction  is  now  made  by  pathologists 
and  clinicists,  but  at  present  these  two  terms  are  in  reference  to 
the  ovaries  used  synonymously.  That  they  have  really  been  so  for 
a  long  time  in  works  upon  gynecology,  is  evident  from  an  examina- 
tion with  reference  to  the  suljject.  Thus  Scanzoni  defines  fibrous 
tumors  of  the  ovaries  to  be  "tumors  formed  of  cellular  tissue," 
and  cysto-sarcomata  as  "tumors  composed  of  cellular  tissue  in  the 
middle  of  which  are  formed  more  or  less  considerable  cavities." 
Peaslee  refers  to  cysto-fibroma,  and  makes  no  mention  of  cysto- 
sarcoma,  while  Barnes  and  G.  Braun  treat  of  cysto-sarcoma  without 
alluding  to  cysto-fibroma.  It  must  be  remembered  that,  even  in 
reference  to  these  affections  in  general,  Rindfleisch'  says,  "I  cannot 
separate  the  fibromas  from  the  sarcomas;  ....  we  distinguish 
three  principal  varieties  of  sarcoma,  namely:  round-celled  sarcoma, 
spindle-celled  sarcoma,  and  fibroma."  "By  cysto-sarcomata,"  says 
Liicke,^  "those  large  tumors  are  especially  meant  which  consist  of 
solid  masses,  papillary  proliferations,  and  numerous  closed  and  open 
cavities,  such  as  are  found  in  the  mammae,  ovary,  and  testicle." 
In  some  cases  the  first  step  in  disease  is  adenoma  ;  then  this  being 
affected  by  sarcoma,  which  undergoes  cystic  degeneration,  the 
result  is  a  combination  to  which  Liicke  gives  the  name  adeno- 
(ysto-sarcoma. 

These  cysts  often  grow  to  a  very  large  size.  In  Mr.  AVells's  ninety- 
first  case  of  ovariotomy  the  operation  was  preceded  by  ta])ping, 
which  removed  thirty-eight  pints  of  thin,  dark  fluid,  containing 
much  cholesterine.  Dr.  Fox,  who  examined  the  tumor,  states  that 
the  cysts  which  were  emptied  by  tapping  represented  one-half  the 
bulk  of  the  mass,  which,  even  after  this,  weighed  thirteen  pounds. 
The  structure  of  the  solid  portion  of  the  tumor  was  very  complex, 


'  Patholog.  Histol.,  Am.  od..  pp.  1:52  and  142.  *  Loc.  cit. 

42 


658  OVARIAN    TUMORS. 

the  cysts  being  of  every  variety  of  size  and  grouped  together  in 
great  confusion.  In  some  the  fluid  was  clear,  and  in  others  like 
pea  soup.  The  proportion  between  the  cystic  and  fibrous  elements 
governs  the  character  of  these  masses  to  such  an  extent  that  it  is 
often  difficult  to  classify  them.  When  the  former  is  much  in  the 
ascendency,  the  growth  resembles  a  fluid  tumor ;  when  the  latter 
predominates,  it  appears  perfectly  solid. 

The  contents  of  the  cyst  may  be  colloid,  purulent,  serous,  or 
sanguinolent,  and  blood  is  sometimes  eftused  between  the  flbrous 
interstices  so  as  to  cause  a  rapid   increase  in  size.      The  cystic, 
sarcoma  sometimes  attains  very  large,  or,  as  Kiwisch  expresses  it, 
"colossal,"  dimensions. 

In  Mr.  Wells's  case,  just  alluded  to,  the  tumor  filled  the  whole 
abdomen,  and  extended  two  inches  above  the  ensiform  cartilage  by 
its  upper  margin,  but  its  growth  Avas  not  nearly  so  rapid  as  that  of 
pure  cystic  disease.  This  case  had  lasted  for  seven  or  eight  years, 
slowly  increasing  until  18G8,  when  it  developed  at  the  following 
rate:  June  to  July,  one  inch;  July  to  August,  one  inch ;  August  to 
September,  one  inch ;  September  to  October,  half  an  inch  ;  October 
to  November,  one  inch. 

Should  one  or  more  large  cysts  be  detected,  relief  to  many  of 
the  symptoms  arising  from  mechanical  interference  may  be  ol)tained 
by  tapping.  The  results  of  the  operation  are,  however,  more 
dangerous  than  in  fluid  tumors,  hemorrhage  and  subsequent  inflam- 
mation often  taking  place  in  consequence  of  it.  Another  disadvan- 
tage attending  it  is  that  the  operator  is  more  limited  as  to  choice 
of  the  point  to  puncture.  Besides  this  means  our  efforts  at  pallia- 
tion must  consist  in  relieving  symptoms  as  they  occur,  in  giving 
support  to  the  mass  by  an  abdominal  bandage,  and  in  enjoining 
quietude  during  menstrual  epochs. 

The  only  curative  treatment  with  which  we  are  acquainted  that 
avails  anything  for  this  form  of  tumor  is  removal  by  ovariotomy. 
The  operation  is  not  so  promising  as  in  case  of  cystic  degeneration, 
and  should  not  be  undertaken  until  the  evil  results  of  tlie  disease 
and  its  tendency  to  destruction  of  life  are  fully  manifested.  It 
requires,  generally,  the  long  abdominal  incision,  and  is  very  likely 
to  be  rendered  difficult  by  adhesions ;  still  the  prospect  of  success 
is  such  as  to  render  the  operation  in  many  cases  of  grave  prognosis 
not  only  admissible,  but  incumbent  upon  us. 

Dermoid  Cysts. — In  various  parts  of  the  body,  the  orbit,  the  floor 
of  the  mouth,  the  brain,  the  eye,  the  anterior  mediastinum,  the 


DERMOID    CYSTS.  659 

lungs,  the  mesentery,  the  testicles,  and  the  ovaries,  a  peculiar  cyst 
containing  fot,  teeth,  hair,  cholesterine,  cartilage,  and  bone  is  some- 
times found.  Its  wall  gives  evidences  of  the  existence  of  sweat 
glands,  sebaceous  follicles,  papillae,  and  an  investing  epithelium,  so 
that  the  microscopic  appearances  of  the  wall  resemble  closely  those 
of  the  skin.  Many  fanciful  theories  have  been  indulged  in  as  to 
the  origin  of  these  peculiar  growths.  It  is  now  generally  believed 
that  they  are  the  result  of  an  irregular  and  eccentric  develojiment 
of  the  tissues  of  the  foetus  during  intra-uterine  life.  It  was  Lebert 
who  advanced  the  theory  that  from  the  elements  present,  sponta- 
neous generation  of  a  portion  of  skin  occurs,  and  this  being  given, 
we  have,  as  Dr.  Farre  expresses  it,  "  the  basis  out  of  which  many 
of  those  products  spring." 

M.  Pigne  has  analyzed  eighteen  cases  with  reference  to  the 
period  of  life  at  which  they  were  found,  with  the  following  results: 

5  existed  in  virgins  under  twelve  years ; 

6  "         children  from  six  months  to  two  years ; 
4          "         the  female  foetus  at  term ; 

3  "         foetuses  cast  off  at  eighth  month.  - 

Dermoid  tumors  vary  in  size  from  that  of  a  hen's  egg  to  that  of 
the  adult  head,  but  very  rarely  grow  larger.  They  are  hanl  and 
generally  globular.  One  ovary  is  usually  affected,  and  by  oidy  one 
tumor;  but  instances  are  on  record  where  a  single  ovary  contained 
a  large  number.  They  usually  consist  of  fat,  long  hairs,  teeth,  skin, 
and  traces  of  bone  intermixed.  The  teeth  are  usually  imbedded  in 
the  cyst-wall  or  attached  to  pieces  of  bone,  and  are  sometimes  very 
numerous.  SchnabeP  records  a  case  in  which  they  exceeded  one 
hundred  in  number,  and  Ploucquet^  one  in  which  they  amounted 
to  three  hundred. 

Histories  of  such  cases  are  so  rare  that  I  transfer  the  following 
from  Prof.  Kiwisch's  work:  "A  girl,  seventeen  years  of  age,  was 
attacked  with  a  swelling  of  the  left  ovary  which,  after  twenty-one 
years,  measured  four  ells  in  circumference,  and  reached  below  the 
knee.  After  her  death,  which  took  place  in  her  thirty-eighth  year, 
it  was  found  that  the  sac  alone  of  the  ovary  weighed  fourteen 
pounds,  and  contained  forty  pounds  of  a  thick,  adipose,  lioney-like 
mass,  which  was  mixed  with  many  hairs  of  different  lengths,  among 
which  curls  were  found  two  inches  long,  and  as  thick  as  a  thumb, 
very  like  elf  locks;  tlie  internal  surface  of  the  sac  was  set  with 

•  Kiwisch,  op.  cit.  *  Becquerel,  op.  cit. 


660  OVARIAN    TUMOES. 

short  hairs.  There  were  also  found  eight  bony  concretions  of 
irregular  shape,  one  of  which  was  seven  and  another  ten  inches 
long,  and  about  two  inches  broad  ;  the  form  of  one  of  these  bones 
was  polygonal,  and  set  with  six  molar  teeth  and  one  incisor,  and 
nine  separate  bones  were  present  besides.  The  teeth  had  the  size, 
|)erfectness,  and  firmness  which  they  generally  have  in  a  girl  twenty 
years  of  age." 

Although  in  themselves  innocuous,  and  not  likely  to  increase 
rapidly  or  to  attain  any  great  development,  they  sometimes  set  up 
very  serious  and  even  fatal  disturbance  by  one  of  three  methods : 
by  creating  suppuration  and  abscess  on  account  of  the  irritation 
kept  up  by  a  foreign  mass  ;  by  perforation  and  discharge  into  the 
peritoneum ;  or  by  the  cyst  which  contains  the  dermoid  elements 
secretin^!;  fluid  and  changing  its  character  to  that  of  a  fluid  tumor. 
Out  of  forty-live  ovarian  tumors  removed  l)y  me,  two  were  large 
cysts  having  as  bases  dermoid  tumors  containing  fat  and  hair,  and 
in  one  case  a  small  fragment  of  bone.  In  these  cases  the  cysts 
containing  the  dermoid  elements  were  not  in  communication  with 
the  laro;e  cysts  tilled  with  fluid  colloid  which  constituted  the  mass 
of  the  tumor.  In  both  cases  the  tumor  was  nearly  removed  when 
a  cyst  tilled  with  fluid,  fat,  etc.,  was  opened  into.  The  large  cysts 
appeared  exactly  like  ordinary  multilocular  cystoma. 

Very  often  they  are  discovered  by  accident  only.  Physical  ex- 
ploration reveals  a  hard,  round  mass,  painless  upon  touch,  and 
unless  the  size  prevent  it,  jyerfectly  movable.  When  of  small  size 
they  require  no  special  treatment,  unless,  as  once  happened  to  Dr. 
Ramsbotham,  they  obstruct  parturition.  When  the  cyst-wall 
undergoes  suppurative  action  and  the  mass  points,  it  should  be 
managed  upon  the  same  principles  as  a  pelvic  abscess.  When  a 
large  cyst  or  cysts  develop,  they  should  be  treated  as  the  ordinary 
cystoma  ovarii. 

We  have  now  reached  the  pro|)er  point  for  the  consideration  of 
the  subject  of  ovarian  cysts  and  cystomata,  which  calls,  on  account 
of  its  paramount  importance,  for  the  closest  investigation  on  the 
part  of  the  gynecologist.  That  it  may  receive  this  I  leave  its  study 
for  a  separate  chapter.  Meantime,  before  leaving  this  part  of  our 
subject,  it  appears  best  to  me  to  say  a  few  words  upon  colloid  degene- 
ration of  the  ovary,  an  affection  which  at  present  holds  in  the  minds 
of  many  a  doubtful  position  as  to  malignancy.  For  a  long  time  the 
generally  accepted  opinion  with  reference  to  colloid  (xoxxo,  "glue," 
and  ftSos,  "like")  or  jelly-like  tumors  was,  that  they  were  of  cancer- 


COLLOID    DEGENERATION    OF    THE    OVARY.  661 

ous  nature,  but  both  in  their  minute  structure  and  in  their  clinical 
features  they  are  so  far  removed  from  true  malignant  disease  that 
the  belief  is  becoming  very  prevalent  that  they  are  not  necessarily 
of  that  character.  This  view  is  now  adopted  by  Drs.  Farre  G. 
Hewitt,  Kiwisch,  Collis,'  Becquerel,  and  most  of  the  more  recent 
writers  upon  the  subject.  In  speaking  of  ovarian  colloid  tumors 
Hewitt  remarks:  "The  latter  designation  (colloid  cancer)  is  not  a 
good  one,  for  an  attentive  consideration  of  the  facts  leads  to  the 
conclusion  that  the  afl'ection  is  not  cancer  at  all."  M.  Bocc^uereP 
seems  to  have  placed  the  question  in  its  proper  light  when  he 
says,  "  Several  diseases  have  been  confounded  under  the  indefinite 
name  of  colloid  c^'sts;  it  is  therefore  essential,  before  advancing, 
to  distinguish  these  different  varieties.  We  shall  now  endeavor 
to  do  this  after  them  (Virchow  and  Bcanzoni),  previously  remarking 
that  under  the  name  of  colloid  matter  some  have  not  at  all  intended 
to  signify  a  cancerous  product,  while  others  have  assigned  it  such 
an  origin."  Virchow^  strongly  expresses  himself  upon  this  point. 
In  speaking  of  the  difference  between  the  form  and  nature  of 
growths,  he  says,  "You  may  therefore  say,  colloid  cancer,  colloid 
sarcoma,  colloid  fibroma.  Here  colloid  means  nothing  more  than 
jelly-like."  He  then  goes  on  to  remark  that  no  confusion  should 
exist  between  such  growths  as  colloid  cancer  and  colloid  degene- 
ration of  the  thyroid  gland  as  to  pathological  significance.  His 
description  of  the  so-called  alveolar  cancer  is  thus  quoted  by  Bec- 
querel: "Small  pouches,  which  are  filled  with  gelatinous  matter 
and  whose  walls  are  lined  by  a  layer  of  epithelium,  are  found  in 
the  parenchyma  of  the  ovary.  These  vesicles  develop  in  every 
direction,  but  more  especially  at  the  periphery  of  the  ovaries,  where 
they  form  masses  of  irregular  shape.  Some  of  them  are  isolated, 
while  others  are  grouped  together  in  the  following  manner.  The 
walls  of  these  vesicles  disappear  by  atrophy  of  cellular  tissue,  when 
they  are  only  formed  by  their  epithelial  lining.  This  becomes  infil- 
trated with  fat,  and  the  walls  forming  the  connection  are  easily 
ruptured.      Those  of  the   large  cyst   remain   intact  and  become 

hypertrophied In  other  cases  the  vesicles  rupture  by 

over-distention ;  from  this  results  hemorrhage,  and  blood  is  found 
in  the  vesicles."  Kiwisch  describes  it  as  a  breaking  up  of  the 
stroma  of  the  ovaries  into  cellular  cavities,  alveoli,  closely  aggre- 
gated together  and  inclosing  a  jelly-like,  semifluid  mass.  By  others 
it  has  been  likened  to  a  sponge  or  a  honeycomb. 


'  Op.  cit.,  p.  205.  2  Op.  cit.,  p.  22G.  ^  Cellular  Palhdl..  p.  512. 


662  OVARIAN    CYSTS. 

It  is  safe  to  conclude,  from  the  present  aspect  of  the  subject, 
that,  while  colloid  deposit  may  coexist  in  the  ovary  with  true  can- 
cer, the  peculiar  breaking  up  of  the  stroma  into  alveoli  which  we 
have  just  described,  is  not  in  itself  a  malignant  aftection,  but  one 
which  seems  to  constitute  a  connecting  link  between  cancer  and  the 
benign  degenerations.  It  frequently  complicates  cancer,  sarcoma, 
and  fluid  tumors.  "We  have  observed,"  says  Kiwisch,  "  alveolar 
degeneration  of  considerable  extent  remain  in  the  system  for  a 
long  series  of  years,  without  any  remarkably  bad  effects." 

Should  a  large  cyst  be  discovered  anywhere,  and  the  size  of  the 
tumor  require  diminution  on  account  of  interference  with  surround- 
ing parts,  paracentesis  may  be  practised ;  but  in  a  pure  alveolar 
tumor,  such  an  accumulation  is  not  common.  Under  these  circum- 
stances, if  the  disease  steadily  advance  and  the  constitution  sufl[er 
in  consequence,  we  should  be  encouraged  by  recognition  of  its  non- 
malignant  nature  to  perform  ovariotomy. 


CHAPTER    XLV. 


OVARIAN  CYSTS  AND  CYSTOMATA. 


This  disease  consists  in  the  development  of  cysts  within  the 
ovary  without  coincident  growth  of  solid  elements,  such  as 
fibroma  or  carcinoma.  Of  all  the  varieties  of  ovarian  tumor  it  is 
the  most  commonly  met  with,  and  hence  for  the  practitioner  it  is 
the  most  important.  It  is  fortunately,  too,  that  which  above  all 
others  is  most  susceptible  of  relief  by  surgery. 

Pathologists  are  still  at  variance  with  reference  to  the  origin  of 
ovarian  cysts.  While  some  with  Wilson  Fox^  agree,  that  "all  the 
forms  of  cysts  met  with  in  the  ovary  originated  from  the  Graafian 
follicles,  and  that  the  multilocular  forms  are  not  the  results  of  any 
special  degeneration  of  the  stroma  ;"  others,  like  Wedl,  doubt  their 
follicular  origin  entirely;  and  others  still,  with  Rindfleisch,  admit 
two  difibrent  sources  of  cystic  formation — one,  the  follicles,  the 
other,  the  interstices  of  the  stroma. 


Med.  Chirurg.  Trans.,  1864. 


OVARIAN    CYSTS.  603 

"In  many  cases,"  says  Rokitansky,*  "they  are  undoubtedly 
formed  from  the  Graafian  follicles,  and  it  appears  that  an  inflam- 
matory process  is  particularly  liable  to  give  the  first  impulse  to 
this  metamorphosis.  They  are  probably,  however,  as  often  new- 
formations  from  the  beginning." 

"  It  was  formerly  very  generally  supposed,"  says  Wedl,^  "  tliat 
the  cysts  in  the  parenchyma  of  the  ovary  originated  in  the  Graafian 
follicles,  but  no  direct  prpof  of  this  was  ever  given." 

Liicke,^  one  of  the  latest  and  most  reliable  authorities,  takes 
even  stronger  ground  against  it  than  Wedl  did.  After  quoting 
Eokitansky's  view^s  he  goes  on  to  say:  "But  we  have  already 
stated  that  cysts  can  only  form  in  the  connective  tissue,  and  only 
after  a  long-continued  irritation;  and  that  it  does  not  look  at  all 
probable  that  such  cysts  should  form  by  spontaneous  exudation. 
As  far  as  the  cystoids  of  the  ovary  are  concerned,  this  theory 
certainly  is  not  admissible.  These  tumors  are  essentially  cysts  from 
broken-down  tissue." 

While  experimental  pathologists  are  testing  this  question,  we 
may  for  the  time  assume  that  there  are  tw^o  entirely  different 
pathological  processes  by  which  true  ovarian  cysts  are  generated : 

1st.  The  follicles  of  De  Graaf  become  filled  with  a  colloid  mate- 
rial, due  to  abnormal  secretion  from  their  walls,  and,  according  to 
Rokitansky  and  Rindfleisch,^  probably  the  result  of  inflammatory 
disease  of  the  wall  of  the  follicle.  This  is  not  the  insignificant 
hydrops  folliculorum  which  creates  small  cysts,  but  a  true  colloid 
degeneration  of  the  follicle  of  much  more  serious  import. 

2d.  A  development  of  cysts  may  occur  in  the  stroma  of  the 
ovary  without  connection  with  the  follicles.  In  this  case,  accord- 
ino;  to  Wedl,  "  the  cvst  consists  in  an  excessive  auo;mentation  of 
volume  of  the  areolae  of  the  areohir  tissue  and  of  the  papillary  new 
formations  composed  of  connective  tissue."  In  this  view  Wal- 
deyer  coincides  in  his  excellent  treatise  upon  ovarian  tumors.'' 

Liicke  makes  Rokitansky's  view  as  to  the  mode  of  formation  of 
these  cysts  in  the  stroma  so  clear  that  I  use  his  words  instead  of 
quoting  the  original :  "  Cysts  may  also  be  generated  by  exuda- 
tion into  new  formed  connective  tissue — the  fluid  distending  the 

'  Op.  cit.,  p.  249.  *  Wedl's  Path.  Histol..  p.  462. 

^  Chapter  on  Tumors  in  Billroth  and  Pitha's  Manual  of  General  and  Special 
Surgery. 
••  Op.  3it.,  p.  515. 
^  Waldeyer,  Eiersfock  und  Ei.,  Leipzig,  1870. 


664  OVARIAN    CYSTS. 

different  bundles,  and  as  they  intersect  in  all  directions,  the  globu- 
lar form  is  the  result ;  thus  numerous  small  spaces  communicate 
with  each  other,  from  their  walls  new  cysts  start,  and  thus  very 
complex  tumors  can  be  formed."  Rindfleisch'  accepts  both  of  these 
sources  of  ovarian  cystoma  in  the  following  words :  "  An  exact 
investigation  also  proves  that  at  least  the  majority  of  all  ovarian 
cysts  proceeds  from  Graafian  follicles;  while,  upon  the  other  hand, 
until  further  information,  a  different  mode  of  origin  must  be 
accepted  for  a  group  of  cysts,  although  not  so  large,  yet,  at  the 
least,  just  as  important." 

The  development  of  a  substance  resembling  the  glandular  ele- 
ment of  the  ovaries,  and  constituting  the  nidus  of  cysts,  has 
recently  attracted  considerable  attention.  In  1862,  Mr.  Spencer 
"Wells  proposed  for  this  the  name  of  "  adenoma"  or  "  adenoid 
tumor."  Further  investigations  appear  to  have  satisfied  patholo- 
gists that  a  degree  of  adenoid  develoi)ment  occurs  in  every  true 
ovarian  cystoma.  Mr.  Wells  himself,  in  his  recent  work  on  Dis- 
eases of  the  Ovaries,  considers  under  the  head  of  adenoid  tumors 
all  simple,  multiple,  and  proliferous  cysts  ;  and  DelafiekP  declares, 
that  "  in  the  ovaries  most  of  the  compound  cysts  are  adenomata, 
with  dilatation  of  the  follicles."  Klebs  strongly  advocates  this 
view.  As  adenoma  is  then  a  frequent  element  of  ovarian  cystomata, 
it  requires  no  separate  and  special  consideration. 

Until  a  recent  period  considerable  attention  has  been  paid  to  the 
character  of  ovarian  cysts,  based  ujion  tbe  existence  of  a  few  and 
of  many  cysts.  Pathologists  are  beginning  to  lay  less  stress  upon 
this  feature  than  they  formerly  did.  Rindfieisch  declares  that  all 
are  multilocular  in  the  beginning,  and  that  they  become  pauei- 
locular,  and,  even  in  rare  cases,  unilocular,  by  fusion  of  adjacent 
cysts  by  breaking  down  of  dividing  septa.  It  must  be  admitted, 
however,  that  there  is  one  class  of  tumors,  the  distinguishing  cha- 
racteristic of  which  is  the  existence  of  a  few  cysts  only,  one  or  two 
of  which  are  usually  very  large,  and  another  which  is  s}iecially 
marked  by  numerous  small  cysts.  The  first  constitutes  the  olygo- 
cystic  tumor  of  Peaslee ;  the  latter  the  poh^cystic  tumor ;  or,  as 
they  are  likewise  styled,  paucilocular  and  multilocular  cysts. 

Each  class  has  usuallj^  certain  well  marked  features,  the  recogni' 
tion  of  which  is  of  value  in  a  practical  point  of  view.  The  first  is 
thus  described  by  Rindfleisch:  "Multilocular  tumors  up  to  the 

'  Op.  cit.,  p.  515.  *  Post-mortem  Examinations  and  Morbid  Anatomy. 


VARIETIES    OF    OVARIAN    CYSTS.  665 

size  of  a  man's  head,  or  unilocular  cysts  up  to  two  feet  in  diameter, 
with  smooth,  but  little  adhering  surface,  and  comparatively  thick, 
fibrinous  walls,  which  are  very  commonly  covered  at  their  inner 
side  with  cauliiiower-like  or  more  tuberous  papillary  excrescences." 
This  is  tlie  form  of  tumor  whicli  he  regards  as  due  to  colloid 
degeneration  of  the  Graafian  follicles. 

The  second  variety  he  describes  in  these  words:  "At  the  place 
of  one  ovarj'  (the  other,  as  a  rule,  is  healthy,  while  in  the  first  form 
the  disease  is  often  of  both  sides)  there  lies  a  tumor,  not  infrequently 
far  above  the  size  of  a  man's  head,  whicli  is  composed  of  several 
large,  and  very  many  smaller,  and  even  the  smallest  cysts.  The 
larger  cysts  are  often  constricted,  and  exhibit,  at  these  places,  the 
remains  of  former  partition  walls  in  the  form  of  fenestrated  mem- 
branes, or  ramified  vascular  strands,  which  evidently  succumb  to  a 
gradual  maceration.  The  surface  of  the  tumor  is  probably  always 
connected  with  the  peritoneum  l)y  a  large  number  of  inflammatory 
adhesions,  upon  which  larger  venous  vessels  run  to  and  fro.  Tlie 
walls  of  the  cyst  are  comparatively  thin,  and  easily  torn."  These 
tumors  he  regards  as  due  to  colloid  degeneration  of  the  stroma. 
"While  the  statement  of  Rindfleisch  that  no  "  fundamental  signi- 

t  ficance"  can  be  attributed  to  the  unilocular  or  multilocular  charac- 
ter of  these  tumors  is  correct  from  an  anatomical  point  of  view,  it 
is  not  the  less  so  that  the  practitioner  is  greatly  aided  in  prognosis 
and  treatment  by  a  recognition  of  the  difterence  between  the  two 

'  forms  of  tumors  just  described;  and  also  of  that  which  exists  be- 
tween them  and  another,  which  being  composed  of  both  cystic  and 
solid  elements,  receives  the  name  of  compound.  We,  therefore, 
proceed  to  consider  the  varieties  of  these  growths  in  reference  to 
the  points  mentioned,  and  to  recapitulate  succinctly  what  has  been 
already  said. 

Ovarian  cysts  are  characterized  by  three  marked  features:  first, 
cysts  with  one  or  very  few  large  compartments;  second,  those  with 
a  great  many  small  compartments  divided  by  thin  cyst  walls  or 

"  thick  trabeculfe;  and  tliird,  those  which  are  composed  of  solid  and 
fluid  elements  in  varying  proportion.     The  first  constitute  the  class 

I  styled  the  monocystic,  unilocular, paucilocular, or  olygocystie  tumor ; 
the  second  that  known  as  the  multilocular  or  poh^cystic  tumor;  and 
the  third  that  which  is  commonly  styled  the  compound  ovarian 
tumor.      "  All   cystoids  are  multilocular  at  the  commencement," 

I  says  Rindfleisch,  but  unilocularization  he  declares  is  especially  fre- 

f  quent  in  those  tumors  arising  from  colloid  degeneration  of  tlie 
.  Grraafian  vesicles.     A  true  monocyst  is  rare,  though  it  may  grow 


666 


OVARIAN    CYSTS. 


to  the  size  of  the  uterus  in  the  nintli  month  of  pregnancy.  Ki- 
wisch^  has  met  with  one  whose  contents  weighed  over  forty  pounds. 
In  the  compound  tumor,  cysts  having  formed  in  the  solid  tissue, 
the  presence  of  solid  and  duid  elements  is  detected  by  examination. 
These  cysts  result  chiefly  from  softening  of  tissue,  or  as  it  is 
expressed  by  liquefaction.  "As  soon,"  says  Billroth,  "as  the  new 
formation  has  separated  into  sac  and  fluid  contents,  in  some  cases 
a  secretion  from  the  inner  wall  of  the  sac  begins,  so  that  the  c^^st 
from  liquefaction  becomes  a  secretion  or  exudation  cyst  and  thus 
grows." 

The  walls  of  ovarian  cysts  consist  of  a  covering  of  peritoneum, 
the  proper  tunic  (tunica  albuginea)  of  the  ovary,  and  an  epithelial 
layer.  The  peritoneum  sometimes  undergoes  great  hypertrophy; 
in  rare  cases  being  half  an  inch  thick. 

The  size  to  which  these  cysts  will  grow  is  truly  wonderful.  It 
has  been  already  stated  that  unilocular  or  monocystic  tumors  are 
rarely  seen  of  very  great  size,  but  instances  are  on  record  of  multi- 
locular  tumors  containing  over  one  hundred  pounds  of  fluid,  and 
Dr.  Copland,  in  the  Diet,  of  Pract,  Med.,  tells  of  an  instance  in 
which  five  hundred  pints  of  fluid  were  drawn  oiF  by  repeated  tap- 
pings, in  twelve  months. 

One  or  both  of  the  ovaries  may  be  affected,  the  right  being  that 
most  frequently  selected  by  the  disease.  The  comparative  frequency 
with  which  the  right  and  left  ovary  are  affected  is  shown  by  the 
followino;  table: 


Authority. 

No.  of  cases. 

Eiffht  side 
aft'ected. 

Left  side 
affected. 

Both  sides 

Safford  Lee  .     .     . 
Chereau   .... 
Scanzoni  .... 

93 

2L5 

41 

50 

109 

14 

35 

78 
13 

8 
28 
14 

Contents  of  Ovarian  Cysts. — This  subject  has  l)een  exhaustively 
investigated  by  Scherer  and  Eischwald.^  By  the  latter  it  has  been 
so  minutely  dealt  with  that  little  is  left  to  be  desired  as  to  the 
chemistry  of  such  fluids. 

These  contents  vary  very  much,  between  a  clear,  albuminous, 
serous  fluid  and  a  thick  gelatinous  material  which  will  flow  through 
no  canula,  and  has  to  be  manually  removed.  The  specific  gravity 
may  be  as  low  as  1007,  though  usually  it  .is  1018  or  1020.  The 
most  important  chemical  constituent  is  an  albuminate  termed  col- 


Op.  cit.,  p.  102. 


2  "Wiirzhur^er  Medizinische  Zeitschrift,  1864. 


I 


CONTENTS    OF    OVAEIAN    CYSTS.  667 

loid,  which  is  usually  more  dense  in  polycystic  than  olygocystic 
tumors,  and  denser  in  small  olygocysts  than  in  the  same  after 
having  assumed  a  large  size.  Tapping  appears  to  increase  the 
density  of  this  fluid  in  olygocysts. 

•  According  to  Eischwald,  two  chemical  transformations  go  on  in 
the  fluids  of  cysts  simultaneously.  Colloid  material  changes  into 
muco-peptone,  while  the  albuminates  transuding  from  the  blood 
are  converted  into  albumino-peptone.  A  species  of  digestion  of 
the  raw  material  goes  on  under  the  heat  of  the  body,  as  Rindfleisch 
expresses  it,  and  consequently  the  larger  and  older  the  tumor  the 
more  fluid  are  the  contents  likely  to  be.  Eischwald  found  these 
fluids  chemically  to  consist  of  the  following  elements : 
Of  the  mucous  order — 

Substance  of  colloid  particles ; 

Mucin ; 

Colloid  substance ; 

Muco-peptone. 
Of  the  albuminous  order — 

Albumen  (and  fibrin); 

Paralbumen ; 

Metalbumen ; 

Albumeno-peptone  (and  fibro-peptone). 

As  an  example  of  the  quantitative  analysis,  the  following  from 
one  of  Eischwald's  cases  will  serve.     1000  parts  contained — 

Water 931.96 

Organic  substances 59.77 

Debris 8.27 

1000.00 
The  debris  (8.27)  contained — 

Salts  soluble  in  water 7.53 

Potas.  sulph 0.08 

•'      chlor 0.59 

Sodae  nat. 6.29 

"     phosph 0.16 

"     carb 0.38 

Loss 0.03 

Salts  insoluble  in  water 0.74 

8.27 

Test  for  Paralbumen. — Leave  the  fluid  at  rest  in  a  cool  ])lace, 
filter  or  decant,  and  thus  separate  sediment  from  supernatant  fluid. 
Pass  a  stream  of  carbonic  acid  gas  through  this  fluid,  and  instantly 
a  precipitate  of  fine  tiocculi  of  paralbumen  will  occur. 


668  OVAEIAN    CYSTS. 

Test  for  Metalbumen. — Digest  another  part  of  tins  fluid  with 
absohite  alcohol  for  three  days.  Filter  ofl:'the  precipitate,  and  heat 
with  distilled  water.  Filter  again  and  metalbumen  may  be  preci- 
pitated b}'  sulphate  of  magnesia.  Paralbumen  is  precijiitated  from 
this  fluid  by  a  few  drops  of  dilute  acetic  acid  and  redissolved  by 
an  excess. 

To  the  naked  eye  the  fluids  of  ovarian  cysts  present  various 
appearances,  as  they  are  tinged  with  blood  or  pus  from  hemorrhage 
or  suppuration  of  the  cyst  walls.  The  varieties  generally  met  with 
are  the  following:  a  light  colored  fluid  like  barley-water;  a  light 
brown  fluid  like  infusion  of  linseed;  a  dark  red  bloody  looking 
fluid;  a  greenish-yellow  colored,  semisolid  gelatine;  a  purulent  fluid 
of  very  oftensive  character  closely  resembling  pea-soup  in  ajjpeai*- 
ance;  very  rarely  an  intensely  black  fluid;  and  in  dermoid  cysts 
a  grumous  gruel-like  mass. 

Does  a  true  ovarian  cyst  large  enough  to  call  for  surgical  inter- 
ference, that  is  to  say,  larger  than  the  size  of  a  child's  head  to  which 
hydrops  folliculorum  sometimes  attains,  ever  contain  fluid  free  from 
albumen  ?  This  is  evidently  a  question  of  a  great  deal  of  import- 
ance. Wells'  and  Barnes  make  three  groups  of  ovarian  fluid,  the 
first  of  which  they  declare  are  devoid  of  fat  and  albumen.  "  Heat 
and  nitric  acid,"  says  the  former,  "  will  neither  coagulate  nor  pre- 
cipitate them."  W.  L.  Atlee  relies  upon  absence  of  albumen  as  a 
sign  that  a  cyst  is  not  ovarian,  and  the  following  interesting  case 
reported  by  J.  L.  Atlee^  will  show  the  estimation  in  which  this 
point  is  held  by  him. 

"I  operated  upon  Mrs.  M.,  aged  over  fifty  .years,  in  October,  1870. 
She  had  labored  under  aljdominal  enlargement  from  the  presence  of  a 
fluid  for  several  j-ears,  and  had  been  tapped  about  twenty-seven  times, 
filling  rapidl3^  after  each  operation.  After  the  last  two  or  three  tappings 
a  small  tumor  remained  in  the  right  iliac  and  pelvic  regions ;  but  at  no 
time  could  albumen  be  detected  in  the  fluid  by  the  orcbnary  tests  of  heat 
and  nitric  acid  ;  hence  I  diagnosed  the  case  to  be  one  of  serous  cyst 
attached  to  the  broad  ligament.  The  presence  of  the  tumor,  as  large  as 
a  turkey's  egw,  in  the  right  iliac  region,  an  unusual  thing  in  serous 
cj^sts,  cast  a  doubt  as  to  its  true  character ;  but  the  inability  to  detect 
albumen  by  the  above  tests  decided  me  against  the  operation,  and  the 
patient  was  sent  home.  Under  these  circumstances,  a  portion  of  the 
fluid  obtained  from  the  last  tapping  was  sent  to  Dr.  Drysdale,  who  gave 
a  verj-  decided  opinion  that  the  fluid  was  from  an  ovarian  cyst.     Upon 

'  Dis.  of  Ovaries.  Am.  ed.,  p.  92. 

2  Essay  by  Dr.  Drysdale,  Trans.  Araer.  Med.  Asso. 


CONTENTS    OF    OVARIAN    CYSTS.  669 

the  strength  of  this  opinion  I  told  the  friends  of  the  patient  that  I  would 
operate  if  she  filled  again. 

"  Accordingl}',  on  the  14th  of  October,  1870,  I  removed  a  cyst  weigh- 
ing, with  the  contained  fluid,  fifteen  pounds,  and  of  an  unusual  character. 
The  upper  half  of  tlie  C3'st  was  very  thin  and  of  a  serous  nature.  Below 
the  urnliilicus  the  c^'st  was  much  thicker,  and,  descending  to  the  pelvis, 
proved  to  be  the  right  ovarium,  having  one  large  cyst  filling  the  abdomen 
above,  with  an  aggregation  of  very  small  cysts  constituting  the  iliac  and 
pelvic  tumor. 

"  The  peculiarity  of  this  case  consisted  in  the  rupture,  probably  at  an 
early  period  of  the  disease,  and  before  I  saw  her,  of  the  tunica  propria, 
or  albugineous  cout  of  the  ovary,  leaving  the  peritoneal  covering  intact, 
and  of  sufficient  strength  to  retain,  not  only  the  small  portion  of  the 
ovarian  secretion,  but  of  tlie  serum  secreted  by  the  pei'itoneal  coat.  This 
also  accounted,  in  some  measure,  for  the  very  rapid  filling  after  each 
tapping." 

The  correctness  of  the  explanation  given  by  Dr.  Atlee  is  open  to 
doubt,  but  his  reliance  upon  presence  of  albumen  as  a  sign  of  ovarian 
cyst  is  fully  shown.  Peaslee^  expresses  himself  in  these  words  "  the 
iluid  of  an  ovarian  cystoma  will  probably  always  be  found  to  con- 
tain albumen  if  it  be  limpid  enough  to  flow  through  the  flue  tube 
of  the  exploring  trocar."  I  can  safely  say  that  I  have  never  met 
with  a  true  ovarian  fluid  which  did  not  contain  albumen. 

The  solid  elements  of  the  fluid  of  OA'arian  cysts  consist  of  the 
results  of  hemorrhage,  and  desquamation  and  fatty  degeneration  of 
epithelial  structures.  In  them  are  found  cholesterine,  fat  globules, 
blood  corpuscles,  and  pigment  cells. 

^lifroar-opiral  AppearaiKcs  of  Ovarian  Fluids. — -The  thinner,  serous 
fluids  present  in  comparison  with  tliose  of  colloid  character  few 
cellular  elements.  In  the  latter,  under  a  power  of  from  300  to  550 
EischwakP  found  such  an  amount  of  morphological  elements  that 
the  fluid  had  to  be  diluted  with  water  before  it  could  be  examined. 
He  then  found  fatty  elements  of  various  size;  round  cells,  some 
serrated;  large  colloid  cells;  round  cells  similar  to  the  pyoid  bodies 
of  Lebert,  or  the  exudative  corpuscles  of  Henle ;  globular  aggrega- 
tions varying  in  size;  scales  of  horny  epithelium;  crystals  of  cho- 
lesterine; dark  brown  pigment;  etc. 

"On  placing  a  drop  of  the  fluid  removed  from  an  ovarian  cyst  under 
the  microscope,"  says  Drysdale,^  "we  usually  find  a  number  of  granular 
cells,  E,  some  free  granular  matter,  c,  and  small  oil  globules,  B  ;  and 
frequently,  in  addition  to  these,  epithelial  cells  of  various  forms,  a,  and 

'  Op.  cit.,  p.  116.  *  Op.  cit.  3  Op.  cit. 


670 


OVARIAN    CYSTS. 


crystals  of  cholesterine,  D.  These,  together  with  blood-corpuscles,  f,  the 
inflammatory  globules  of  Gluge,  i,  the  pus  cell,  g  h,  and  disintegrated 
blood  and  other  cells,  may  all  bo  sometimes  seen  floating  in  either  a  clear 
or  a  turbid  fluid." 

Fig.  175. 

E 


Microscopic  appearance  of  ovarian  fluid.     (Drysdale.) 

Eor  the  microscopist  and  pathologist  all  these  are  of  interest. 
For  the  ovariotomist  this  is  the  chief  point  of  importance :  is  there 
any  characteristic,  pathognomonic  cell,  or  element  wpon  the  pres- 
ence of  which  a  positive  diagnosis  of  ovarian  cyst  may  he  hased? 
When  this  question  can  be  unreservedly  answered  in  the  affirmative 
a  great  advance  will  have  been  made  in  this  important  matter. 
Spiegelberg,  in  an  interesting  lecture  upon  the  diagnosis  of  ovarian 
tumors,  enumerates  cylindrical  epithelium,  colloid  cells,  cholesterine, 
etc.,  and  appears  to  rely  upon  the  character  of  cells  furnished  by  the 
part  from  which  the  material  was  secreted  rather  than  uppn  any 
particular  cell. 

Long  ago,  I^unn  pointed  out  the  existence  of  the  "  gorged 
granule"  though  not  as  a  diagnostic  point,  and  Paget,  Bennett, 
Gluge,  and  others  speak  of  the  "  granular  corpuscle,"  the  "  compound 
granular  cell,"  and  the  "inflammation  globules."  In  an  essay, 
already  referred  to,  Dr.  T.  M.  Drysdale,  of  Philadelphia,  has  recently 
described  a  cell  which  he  calls  "the  ovarian  granular  cell,"  which, 


CONTENTS    OF    OVARIAN    CYSTS.  671 

when  found  in  pelvic  tumors,  he  regards  as  pathognomonic  of 
ovarian  disease,  and,  as  such,  he  looks  upon  its  diagnostic  value  as 
very  great.  This  matter  is  of  so  great  importance,  that  I  prefer  to 
describe  this  cell  in  Dr.  Drysdale's  words.  In  referring  to  the  cells 
shown  in  Fig.  175  he  says: 

"To  find  them  all  present  in  one  specimen,  however,  is  rare;  more 
commonly  we  can  discover  but  three  or  four  of  them  in  the  fluid.  But 
no  matter  lohat  other  cells  may  be  present  or  absent,  the  cell  ivhich  is 
almost  invariably  found  in  these  fluids  is  the  granular  cell. 

"  This  granular  cell,  E,  in  ovarian  fluid,  is  generally  round,  but  sometimes 
a  little  oval  in  form,  is  very  delicate,  transparent,  and  contains  a  number 
of  fine  granules,  but  no  nucleus.  The  granules  have  a  clear,  well-defined 
outline.  These  cells  differ  greatly  in  size,  but  the  structure  is  always  the 
same.  They  maj'  be  seen  as  small  as  the  one  five-thousandth  of  an  inch 
in  diameter,  and  from  this  to  the  one  two-thousandth  of  an  inch.  In 
some  instances  I  have  found  them  much  larger,  but  the  size  most  com- 
monly met  with  is  about  that  of  a  pus  cell. 

"  The  addition  of  acetic  acid  causes  the  granules  to  become  more  distinct, 
while  the  cell  becomes  more  transparent.  When  ether  is  added  the  gran- 
ules become  nearly  transparent,  but  the  appearance  of  the  cell  is  not 
changed. 

"This  granular  cell  may  be  distinguished  from  the  pus  cell,  l^nnph 
corpuscle,  white  blood  cell,  and  other  cells  which  resemble  them,  both  by 
the  appearance  of  the  cell  and  by  its  behavior  with  acetic  acid. 

"The  pus  and  other  cells,  o,  which  have  just  been  named,  have  often  a 
distinctly  granular  appearance  ;  but  the  granules  are  not  so  clearly  defined 
as  in  the  granular  cell  found  in  ovarian  disease,  owing  to  the  partial 
opacity  of  these  cells;  and  when  the  granular  cell  of  ovarian  disease  and 
the  pus  cell  are  placed  together  under  the  microscope,  this  difference  is 
very  apparent.  In  addition  to  the  opacity  of  these  cells,  we  frecpiently 
find  their  cell  wall  appearing  wrinkled  rather  than  granular ;  and  further, 
in  the  fresh  state,  they  are  often  seen  to  contain  a  body  resembling  a 
nucleus. 

"  But,  if  there  is  doubt  as  to  the  nature  of  the  cell,  the  addition  of  acetic 
acid  dispels  it;  for,  if  it  is  a  pus  cell,  or  any  of  the  cells  named  above, 
lit  will,  on  adding  this  acid,  be  seen  to  increase  in  size,  become  very 
transparent,  and  nuclei,  varying  in  numlier  from  one  to  four,  will  become 
visible.  (Hee  a,  pus  cell  before  jidding  ncid  ;  and  H,  pus  cell  after  adding 
acid.)  Should  the  cell,  however,  be  an  ovarian  granular  cell,  the  addition 
of  this  acid  will  merely  increase  its  transparency  and  show  the  granules 
more  distinctly. 

"The  compound  granular  cell,  i,  the  granule  cell  of  Paget  and  others, 
or  inflammation  corpuscle  of  Gluge,  is  also  occasionally  i)resent  in  these 
fluids,  and  might  possibly  be  mistaken  for  the  ovarian  granular  cell;  but 


672  OVARIAN    CYSTS. 

it  is  not  difficult  to  distinguish  them  from  each  other.  Gliige's  cell  is 
usually  much  larger  and  uiore  opaque  than  the  ovarian  cell,  and  has  the 
appearance  of  an  aggregation  of  minute  oil  globules,  sometimes  inclosed 
in  a  cell  wall,  and  at  others  deficient  in  this  respect.  The  granules  are 
coarser,  and  vary  in  size,  while  the  granules  of  the  ovarian  cell  are  more 
uniform  and  very  small.  By  comparing  them  in  the  drawing  these  diffei"- 
ences  will  be  apparent.  Again,  the  behavior  of  these  cells  on  the  addition 
of  ether  will  at  once  decide  the  question ;  for,  while  the  ovarian  cell  re- 
mains nearly  iinatfected  b^^  it,  or,  at  most,  has  its  granules  made  paler, 
the  cell  of  Gluge  loses  its  gi-anular  appearance,  and  sometimes  entirely- 
disappears  through  the  solution  of  its  contents  by  the  ether. 

"  That  the  discovery  of  a  granular  cell  in  ovarian  fluid  is  new,  T  do  not 
assert,  as  J.  Hughes  Bennett  and  other  writers  have  described  granular 
cells  which  they  have  seen  in  these  fluids;  but,  with  one  exception,  their 
description  does  not  correspond  with  the  ovarian  granulai'  cell.  Bennett,' 
for  instance,  states  that  the  granular  cell  wliich  he  saAv  exhibited  a  distinct 
nucleus  on  the  addition  of  acetic  acid,  which  is  not  the  case  with  this. 
Other  writers  have  described  the  cells  which  they  found  as  pus  and  pyoid 
cells ;  and  yet  otiiers  confound  tlu^n  with  the  compound  granular  cell,  or 
inflammation  globules.  The  exception  referred  to  above  is  found  in 
Beale's  description  of  the  microscopic  appearance  of  ovarian  fluid. "^ 

The  description  given  l)y  Beale  he  declares  to  correspond  closely 
to  that  of  Ins  "ovarian  granular  cell,  hut  it  is  incomplete,  and  no 
test  is  given  hy  ■which  to  distinguish  it  from  other  granular  cells.'" 
Dr.  Drysdale  therefore  claims  to  have  been  tlie  tirst  to  describe  a  ^ 
cell  which  has  never  been  accurately  described  before,  and  to  have  "^ 
given  the  tests  by  which  it  may  be  distinguished  from  others  such 
as  the  pus  cell,  the  white  blood  corpuscle  and  the  compound  granule 
cell  which  closely  resembles  it.     lie  sums  up  in  these  words: 

"I  claim  then,  that  a  granular  cell  has  been  discovered  by  me  in  ovarian 
fluid,  which  differs  in  its  behavior  with  acetic  acid  and  ether  from  any 
other  known  granular  cell  found  in  the  abdominal  cavit}-,  and  which,  by 
means  of  these  reagents,  can  be  readily  recognized  as  the  cell  which  has 
been  described ;  and  further,  that  by  the  use  of  the  microscope,  assisted 
by  these  tests,  we  may  distinguish  the  fluid  removed  from  ovarian  cysts 
from  all  other  abdominal  dropsical  fluids."* 

'  Ed.  Mod.  and  Snrg.  Journ.,  vol.  Ixv.  p.  280.  1846. 

"  The  Microscope  in  its  Application  to  Practical  Medicine.  By  Lionel  S.  Bealc. 
M.B.,  F.R.S.,  etc.     3d  edit.,  p.  179. 

^  The  views  of  Dr.  Drysdale  are  not  yet  verified.     The  matter  is  at  present  suh 
_  judice. 


CAUSES.  673 

Causes. — Very  little  is  positively  known  upon  this  subject.  The 
predisposing  causes  which  are  generally  admitted  are  the  following. 

Age ; 

Childbearing; 
Chlorosis ; 

Scrofulous  diathesis ; 
Menstrual  disorders. 

It  should  be  borne  in  raind  that  even  as  to  some  of  these  there  is 
doubt  and  variance  of  opinion  among  gynecologists. 

The  great  predisposing  cause  is  age,  the  affection  commonly 
showing  itself  during  the  period  of  ovarian  activity,  and  very 
generally  during  that  of  the  most  vigorous  activity.  It  is  rare 
under  twenty  and  over  fifty,  the  most  common  period  of  its  occur- 
rence being  between  twenty  and  forty.  It  may,  however,  occur  as 
early  as  thirteen  or  fourteen,  and  as  late  as  sixty,  and  a  slight 
degree  of  cystic  degeneration  has  been  seen  in  infancy.  A  case 
lias  recently  been  recorded  in  which  ovariotomy  was  successfully 
performed  upon  a  child  of  six  years  of  age.' 

Scanzoni  records  97  cases,    70  of  which  were  from  18  to  40. 
Ch^reau        "      230  cases,  1.33  "  "  17  to  37. 

Lee  "      135  cases,    82  "  "  20  to  40. 

Of  Scanzoni's  cases  five  were  between  fifty-five  and  sixty ;  of 
Lee's  one  hundred  and  thirty-five  cases,  eighty-eight  were  mar- 
ried, thirty-seven  unmarried,  and  eleven  widows.  With  refer- 
ence to  the  propriety  of  admitting  the  other  causes  there  is  much 
doubt. 

The  uncertainty  existing  as  to  the  exciting  causes  is  even 
greater  than  this.  All  those  influences  which  theoretically  would 
l)e  likely  to  excite  cystic  growth,  as  ovaritis,  blows,  checking  of 
menstruation,  excess  of  coition,  libidinous  desires  without  gratifi- 
cation, have  been  advanced  by  authors  as  scientific  certainties. 
Jjut  proof  is  wanting,  however  plausible  the  theoretical  reasoning 
appears,  and  they  cannot  in  the  present  state  of  science  be  ad- 
nutted.  In  the  great  majority  of  cases  these  tumors  develop  in 
women  who  have  led  rational  and  quiet  lives,  in  whom  no  prejudi- 
cial influence  can  be  discovered  as  having  existed,  and  wlio  liave 
detected  the  o-rowth  of  the  tumor  wlien  imagining  themselvts  in 
very  fair  health. 

Certainly  nothing  can  witli  safety  be  assumed  ])eyon(l  this,  that 


'  Med.  Press  and  Circular,  March  26,  1873. 
43 


674  OVARIAN    CYSTS. 

it  is  probable  that  those  influences  which  keep  up  and  intensify 
ovarian  congestion,  and  interfere  with  ruptnre  of  the  follicles  of 
De  Graaf,  tend  to  produce  cystic  and  follicular  degeneration. 
Kiwisch,  Rokitansky,  and  Rindfleisch  all  agree  in  thinking  it 
probable  that  inflammation  aftecting  the  wall  of  the  vesicle  has 
an  influence  on  the  production  of  the  disease. 

Natural  History  of  Ovarian  Cysts. — Ovarian  cysts  develop  either 
by  one  or  by  a  number  of  cysts.  In  the  flrst  case  the  cyst  may 
become  fully  distended  by  fluid,  reach  a  point  where  its  growth 
ceases  and  remain  quiescent,  only  annoying  the  patient  by  the 
mechanical  results  of  its  presence  and  the  apprehension  tliat  it  may 
increase  and  create  trouble.  There  are  no  grounds  for  doubting 
the  evidence  that  such  tumors  may  remain  without  increase  for 
even  forty  or  fifty  years,  but  such  cases  are  rare  exce]tti()ns  to  a 
general  rule.  "Much  mischief  has  resulted,  however,"  says  Hew- 
itt, "from  looking  on  such  cases  as  the  typical  ones,  while  the  large 
majorit}'  of  the  cases,  the  end  of  which  is  naturally  death  in  a  much 
shorter  time,  have  been  considered  as  the  exceptional  ones." 

We  now  and  then  meet  with  pulmonary  tuberculosis  which 
goes  on  to  formation  of  a  large  cavity,  and  then  for  some  unac- 
countable reason  ceases  to  advance  The  cavity,  which  is  dis- 
tinctly discernible,  remains  quiescent,  and  the  patient  may  live  for 
years.  As  this  is  an  exception  to  a  rule  in  the  natural  history  of 
phthisis,  so  is  the  tardy  course  of  ovarian  dropsy  just  alluded  to  an 
exception  to  the  usual  course  of  that  affection.  The  olygocystic 
tumor  grows  much  more  slowly  than  the  polycystic,  and  this  is  the 
more  marked  as  it  a[)})roaches  the  monocystic  type.  I  removed  one 
which  had  been  under  my  own  observation  for  nine  years,  and 
only  at  the  end  of  this  time  did  its  existence  aflfcct  the  constitution. 

If  its  type  be  multilocular,  tlie  tumor  advances  more  rapidly 
certainly,  and  uncontrollably,  than  in  the  case  just  mentioned. 
The  prognosis  of  ovarian  dropsy  not  interfered  with  by  art  (and  by 
this  we  mean  surgical  art,  as  medicine  has  no  controlling  or  cura- 
tive power  in  the  disease)  is  always  unfavorable.  The  average 
duration  of  the  cases  of  both  types  is  supposed  by  the  best  modern 
authorities  to  be  about  three  years  of  life  after  the  inception  of  tlie 
afltection. 

Mr.  Saffbrd  Lee  has  collected  statistics  as  to  the  duration  of 
the  disease  in  ]23  cases,  not  subjected  to  any  curative  surgical 
treatment. 


CONDITIONS    AFFECTING    OVARIAN    CYSTS.  675 

In  38  the  duration  was 1  year. 

"    25    ''  "  " 2  years. 

"    17    '•  '•  '• 3     - 

"    10    "  •'  " 4     " 

"4 '  .....  5     " 

"      5    '■         "  '' 6     " 

'<  ^        I.  K  II  ^  f7  (( 

"      3    "  '•  " 8     " 

"    17 '  ....        9  to  50     " 

From  this  it  will  be  seen  that  out  of  123  cases  80  terminated 
within  three,  and  94  within  jfive  years.  At  the  same  time  that  the 
fact  must  not  be  lost  sight  of  that  17  out  of  123  cases  lasted  over  nine 
years,  and  that  some,  the  number  of  which  is  not  stated,  terminated 
at  the  end  of  fifty,  it  must  not  be  accepted  as  certain  that  these  were 
cases  of  true  ovarian  cj^stoma.  Experience  in  this  affection  leads  to 
the  suspicion  that  these  were  instances  of  dermoid  cysts,  or  of  some 
variety  of  abdominal  tumor  which,  while  it  closely  simulates  ova- 
rian cystoma,  runs  a  much  more  benign  course. 

Siwntaneous  Cures  of  Ovarian  Cysts. — Sometimes  nature  effects  a 
cure  in  one  of  the  following  wn^'s.  The  cyst  may  discharge  into  the 
peritoneum  and  absorption  occur.  Of  this  accident  Dr.  Tilt  lias  col- 
lected 71  cases,  of  which  30  recovered,  19  were  improved,  and  21 
died.  I  have  met  with  two  instances  of  such.rupture,  both  of  which 
proved  fatal  by  peritonitis.  The  cyst  walls  may  undergo  calcareous 
degeneration,  which  checks  advance.  The  cyst  may  discharge 
externally  by  the  abdominal  or  dorsal  surfaces,  or  into  the  rectum, 
bladder,  vagina,  or  uterus  by  means  of  the  Fallopian  tubes.  In- 
stances of  the  last  occurrence  are  mentioned  by  Morgagni,  Frank, 
Follin,  and  Boivin,  and  Richard  records  five  cases. 

With  reference  to  nature's  power  alone,  or  aided  by  absorbents, 
to  remove  the  accunmlated  fluid,  Kiwisch  declares,  "We  must 
express  our  dissent  from  the  opinion  of  those  practitioners  who 
assume  that  an  ovarian  cyst  can  l)e  completely  removed  by  simple 
absorption.  So  far  as  we  know,  this  process  has  not  been  satisfac- 
torily demonstrated  by  a  single  case."  It  is  the  oj.inion  of  many 
that  al)Sorption  of  the  contents  of  these  cysts  does  occur,  and  nunu'- 
rous  instances  are  cited  in  proof;  but,  in  these  cases,  the  doubt  arises 
whether  a  true  cystoma  ovarii  existed,  or  one  of  the  iieriuterine 
cysts  which  so  closel}^  resemble  it. 

Diseased  Conditions  affecting  Ovarian  Cysts.— 1  have  already 
alluded  to  suppurative  inflammation  of  the  cyst  walls,  which  may 
occur  m  consequence  of  tapping,  or  without  operative  interference. 
The  pulse  and  temperature  become  elevated,  the  patient  restless  and 


676  OVARIAN    CYSTS. 

depressed,  profuse  perspirations  occur,  diarrhoea  sets  in,  and,  unless 
relieved,  the  patient  dies  with  hectic  synii)tonis.  In  a  number  of 
instances  ovariotomy  has  been  successfully  performed  under  these 
circumstances.  One  such  case  is  recorded  hy  Keith,  the  suppurative 
action  occurring  seven  days  after  tapping:  three  by  Wells;  one  by 
Peaslee ;  and  one  by  Teale.*  I  liave  operated  upon  one  case  in 
which  ovariotomy  was  undertaken  only  as  a  last  resort.  The  con- 
tents of  the  cyst  were  excessively  fetid,  and  the  patient  very  ill  at 
the  time  of  operation.  A  favoralde  termination,  however,  occurred. 
In  another  case,  in  which  I  practised  drainage  by  the  vagina,  suppu- 
rative inllammation  occurred,  and  eventuated  in  gangrene  of  the 
cyst  wall  and  death. 

Twisting  of  the  pedicle  is  another  accident  which  sometimes 
takes  place.  Gallez^  in  referring  to  this  says,  "  this  very  curi- 
ous and  happy  termination  of  ovarian  cysts  is  unfortunately  very 
rare,  and  likewise  very  difficult  of  artificial  accomplishment; 
its  effect  is  to  produce  strangulation  of  the  tumor."  Where 
the  interference  thus  established  in  the  vascular  supply  of  the 
tumor  goes  just  far  enough  to  produce  gradual  atrophy,  cure  may 
be  effected,  and  post-mortem  evidence  of  such  an  occasional  occur- 
rence exists.  Ordinarily  strangulation  and  death  of  the  tumor 
occur,  which  destroy  life  unless  ovariotomy  sliould  intervene.  In 
1865,  Rokitansky  pul)rislie(l  an  essay  niion  this  subject,  and  since 
that  time  it  has  attracted  considerable  attention.  lie  cited  the 
details  of  thirteen  cases,  and  Spencer  Wells  mentions  two  deaths 
thus  caused  before  operation,  and  twelve  cases  discovered  by  him 
upon  performance  of  ovariotomy.  Klob  reports  an  instance  in 
which  a  tumor  turned  upon  its  pedicle  five  times;  and  in  a  case  of 
fatal  hemorrhage  into  the  cyst  Patruban  found  in  autopsy  torsion 
of  the  pedicle  creating  venous  stenosis  and  rupture.^  Crane^  and 
Tait®  record  cases  in  which  small  cysts  were  thus  rendered  gangre- 
nous, in  consequence  of  which  the  patients  died  by  septicremia. 

Sometimes  an  ovarian  cyst  increases  very  suddenly  in  dimensions, 
great  pain  from  distention  occurs,  and  symptoms  of  loss  of  blood 
develop  tliemselves.  This  is  due  to  hemorrhage  from  the  cyst  wall. 
In  two  cases  in  mj-  experience  it  has  occurred  ;  in  one  ovariotomy 
demonstrated  the  source  of  the  difficulty;  and  in  the  other aspira- 


•  London  Lancet,  Am.  reprint.  Sept.  1873. 

2  L.  Gallez,  Histoire  des  Kystes  de  I'Ovaire.  Bruxelles,  1873.  p.  150. 
'^  London  Lancet,  Am.  reprint,  Sept.  1873. 

*  Amer.  Med.  Monthly,  April.  1861.  ^  ^din.  Med.  Journ.,  1861. 


METHODS    IN    WHICH    DEATH    IS    PRODUCED.  677 

tion,  adopted  on  account  of  the  severe  suftering  from  disfeution,  did 
so.  Parry'  records  a  case  which  ahnost  proved  fatal  from  this  cause, 
and  Patruban^  one  which  did  so.  In  the  latter  case  torsion  of  the 
pedicle  seemed  to  have  produced  the  rupture  of  vessels.  Wonder 
at  such  an  occurrence  will  cease  when  it  is  remembered  that  veiiis^ 
as  large  as  the  little  finger  have  been  found  between  the  outer  and 
middle  layer  of  cysts. 

Conditions  likely  to  conipli.cate  Ovarian  Cysts. — They  may  be  com- 
plicated by  pregnancy;  ascites;  fecal  impaction;  Bright's  disease; 
pleuritic  effusion;  peritonitis  with  adhesions;  a  low  type  of  gas- 
tritis marked  by  intensely  red  tongue,  constant  vomiting,  and  ten- 
derness of  the  stomach;  a  low  grade  of  septicaemia;  diarrhoia; 
inguinal,  umbilical,  and  crural  hernia,  etc. 

Methods  in  which  Death  is  produced. — There  are  several  modes  in 
which  ovarian  dropsy  produces  its  usual  fatal  results  when  un- 
interfered  with  by  surgical  means. 

1st.  A  cyst  may  rupture  and  produce  peritonitis,  either  before  or 
after  su})purative  inflammation  of  its  walls. 

2d.  Inflammation  of  the  cyst  wall  may  result  in  the  filling  of 
the  cyst  with  pus,  which  produces  hectic  and  in  time  exhaustion 
and  death. 

3d,  Fatal  hemorrhage  may  occur  into  the  cyst. 

4th.  Prolonged  interference  with  the  functions  of  nutrition  and 
respiration  may  sap  the  powers  of  life. 

5th.  Death  of  the  cyst  may  occur  from  twisting  or  rupture  of 
the  pedicle  and  cause  septicaemia. 

6th.  A  low  grade  of  gastritis,  pleuritis,*  or  enteritis  may  produce 
exhaustion. 

7th.  Finally,  from  the  combined  depreciating  influences  of  this 
condition,  gradual  or  sudden  prostration  of  strength  may  close  tlie 
scene  by  death. 

We  now  approach  the  important  subject  of  symptomatology  of 
ovarian  cysts  and  their  difterentiation  from  other  morbid  conditions 
met  with  in  the  abdomen.  As  the  study  of  that  subject  will  fre- 
quently involve  allusion  to  pelvic  cysts  closely  resembling  ovariai: 
but  yet  entirely  distinct  from  the  ovaries,  I  deem  it  best  to  take  a 
rapid  survey  of  them  here. 

Cysts  of  the  Broad  Ligaments.— Gy?^\^  of  considerable  size  some- 
times form   between   the   layers    of  i»eritonenni    making    uj.   the 


'  Am.  Journ.  Obstet.,  Nov.  1871.  *  Gallez,  op  cit.,  p.  15n. 

3  T.  S.  Lee. 

*  I  have  seen  two  cases  in  which  hydrothora.x  proved  a  great  source  of  prostration. 


678  OVARIAX    CYSTS. 

envelopes  of  the  broad  ligaments.  They  are  sui>posed  to  arise  froni 
the  collection  of  fluid  in  the  meshes  of  areolar  tissue  of  the  liga- 
ments, or  from  the  parovaria  or  bodies  of  Rosenmiiller.  Within 
the  external  margin  of  the  broad  ligament,  where  the  two  walls  ol" 
the  peritoneum  pass  from  the  limbripe  of  the  tube  to  the  ovary, 
exists  the  body  of  Rosenmtiller,  parovarium,  or  Wolthan  body,  to 
which  allusion  has  already  been  made  as  consisting  of  a  number 
of  little  tortuous  cords,  some  of  which  are  perforated  by  canals. 
The  slight  secretion  occurring  from  the  walls  of  these  tubes  some- 
times becomes  greatly  increased,  and  the  containing  walls  becoming 
proportionately  distended,  a  tumor  is  created.  These  cysts  may 
attain  a  large  size,  though  they  do  not  generally  do  so. 

One  of  the  most  interesting  cases  of  cyst  of  the  broad  ligament 
which  T  have  seen  in  practice  was  in  a  lady  from  Mol)ile,  upon 
whom  ovariotomy  was  succesfully  performed  by  the  late  Dr.  Xott, 
of  this  city.  He  had  tapped  her,  and  drawn  oft'  a  large  amount  of 
limpid  fluid  four  years  before  the  operation,  {ind  the  cyst  had  for 
about  three  years  appeared  to  have  closed.  After  that  time,  how- 
ever, it  had  refilled,  and  was,  when  I  first  saw  her  in  consultation 
with  Dr.  Nott,  quite  tense,  and  the  abdomen  appeared  of  about  the 
size  of  that  of  a  woman  in  the  seventh  month  of  pregnancy. 
Operation  was  determined  upon,  but  delayed  for  three  months  in 
consequence  of  the  heat  of  the  weather.  When  it  was  performed, 
both  ovaries  were  found  to  be  perfect  in  size  and  shape,  and  the 
cyst*  was  found  to  occupy  the  left  broad  ligament,  the  })eritoneal 
walls  of  which  were  immensely  distended  over  its  surface. 

The  peculiar  features  which  have  been  found  to  characterize  cysts 
of  the  broad  ligaments  are  the  following.  They  contain  a  clear, 
limpid,  very  slightly  albuminous  liquid,  which  takes  on  a  purplish 
tinge  when  exposed  to  the  rays  of  the  sun;  tapping  generally, 
though  not  always,  cures  them;  after  tapping  no  cyst  can  be  felt; 
they  are  always  unilocular;  and  they  have  been  found  to  contain 
in  their  walls  nonstriated  muscular  fibre,  which  the  walls  of  ovarian 
cysts  never  contain. 

Parasitic  or  Hydatid  Cysts. — Although  cases  of  these  cysts,  de- 
veloped in  consequence  of  the  presence  of  the  echinococcus  hominis 
and  cysticercus  cellulosre,  are  reported  as  having  occurred  in  the 
ovaries,  it  is  doubtful  whether  such  reports  are  authentic.  These 
parasites  may,  however,  develop  in  the  mesentery,  the  omentum 


'  This  cyst  is  now  in  iny  possession.     Dried  and  stuffed  with  cotton,  it  measures 
26  inches  in  circumference. 


TUBAL    DROPSY.  679 

majus,  and  even  in  the  cellular  tissue;  the  vesicle  of  which  the 
parasite  consists  becoming  surrounded  by  a  neoplastic  sac.  "  I 
have  seen,"  says  Billroth,  "  cysticercus  vesicles  removed  from  the 
tongue  and  nose,  echinococcus  vesicles  removed  from  the  hack  and 
thigh."  Spiegelberg  reports  a  case  of  retro-uterine,  left  sided  para- 
sitic cyst,  simulating  ovarian  cyst,  in  which  he  cut  down  and  re- 
moved some  of  the  characteristic  contents.  This  procedure  and 
tapping  or  aspiration  are  the  oidy  means  of  diagnosis  which  are  at 
all    reliable. 

Tubal  D)-opsy. — This  condition,  which  is  described  under  the 
names  of  h^'drops  tubte,  salpingian  dropsy,  and  hydrosalpinx,  con- 
sists in  the  distention  of  the  Fallopian  tubes  by  muco-serous  fluid. 
It  arises  in  this  manner:  some  influence,  for  example,  acute  or 
chronic  salpingitis,  pelvic  peritonitis,  or  cellulitis,  occludes  both 
extremities  of  the  tube.  The  inflammation  of  the  mucous  mem- 
brane of  the  tube  creating  a  muco-serous  fluid,  the  canal  is  dis- 
tended by  this,  generally  irregularly,  to  the  size  of  the  finger  or 
small  intestine.  Thus  far  the  afiection  does  not  concern  our 
present  investigation,  for  there  is  no  probability  that  such  a 
growth  would  resemble  ovarian  tumor  so  closely  as  to  lead  to  an 
error  in  diagnosis.  But  as  this  distention  goes  on,  the  mucous  lining 
of  the  tube  takes  on  the  anatomical  and  physiological  characters  of 
a  serous  membrane,  and  secretes  plentifully  a  serous,  straw-colored, 
and  slightly  flocculent  fluid.  At  times  the  distention  of  the  walls 
of  the  tube  proceeds  so  far  that  the  fluctuating  tumor  which  results 
gives  all  the  physical  signs  of  ovarian  dropsy. 

The  testimony  of  authorities  is  almost  unanimous  that  between 
this  condition  and  ovarian  dropsy  there  are  no  means  of  diagnosis 
without  withdrawal  of  some  of  the  fluid.  M.  Aran  sounds  tlie 
key-note  to  the  general  belief  when  he  declares  that,'  "  the  tube 
distended  by  liquid,  I  am  perfectly  assured,  does  not  give  a  sutii- 
ciently  clear  sensation  to  allow  us  to  diagnosticate  its  existence." 
Prof.  Simpson,  however,  assumes  a  different  position.^  He  declares 
that,  although  "in  practice  this  form  of  tumor  is  usually  altogether 
overlooked  or  is  mistaken  for  some  other  kind  of  tumor,"  it  is 
really  diagnosticable  by  the  following  means:  "1st,  its  free  and 
independent  mobility;  2d,  its  elongated  form;  and  3d,  its  wavy 
outline."  Let  any  one  examine  the  shape  of  a  large  tui)al  dropsy, 
like  that  represented  at  Fig.  176,  for  instance,  and  he  will  see  that 
both  the  shape  and  wavy  outline  will  fail  him.     When  it  is  re- 

'  Op.  cit.,  p.  033.  ^  Op.  cit.,  p.  432. 


680  OVARIAN    CYSTS. 

raembered  tliat  tlie  affection  frequently  results  from  pelvic  [lerito- 
uitis,  it  will  be  apparent  that  the  freedom  of  motion  will  be  often 
delusive.  "  The  diseased  tube,"  says  Courty,^  "  is  rarely  free  and 
without  alteration  at  its  periphery:  generally  it  bears  signs  of  old 

Fiff.  176. 


Tubal  dropsy.     (Hooper.) 

inflammation,  which  is  adhesive,  and  this  fixes  it  to  the  neighbor- 
ing parts."  I  have  met  with  the  aflection  four  or  five  times  in 
autopsies,  and  this  statement  has  always  been  sustained. 

The  means  of  diagnosis  just  mentioned  would  be  applicable  to 
slight  tubal  distention,  which  is  rarely  productive  of  symptoms 
calling  for  examination.  Few  instances  of  diagnosis  are  on  record, 
and  even  in  cases  wiiere  tapping  has  been  supposed  to  substantiate 
it,  it  is  by  no  means  sure  that  such  a  disease  existed.  Prof 
Simpson  reports  but  one  case  in  his  extensive  experience  in  which 
he  was  able  to  come  to  a  conclusion.  lie  denies  the  possibility  of 
great  enlargement  of  these  tumors,  declaring  that  they  rarely  grow 
larger  than  a  fffital  head,  and  that  we  may  justly  be  allowed  to  be 
sceptical  as  to  cases  reported  as  being  much  larger.  Dr.  Arthur 
Farre,-  however,  willingly  admits  the  well-known  cases  of  Bonnet 
and  De  Haen  ;  the  first  of  which  contained  thirteen  pounds  of  fluid 
and  the  second  thirty-two  pounds.  Scanzoni  circumstantially 
reports  an  instance  in  which  the  sac  attained  the  size  of  the  head 
of  a  child  of  ten  years  of  age. 

Subperitoneal  Cysts. — Cystic  degeneration  is  much  more  likely  to 
occur  in  those  organs  which  have,  as  component  parts  of  their 
structure,  minute  cavities  lined  by  epithelium.  Thus,  the  kidneys 
and  ovaries  are  peculiarly  liable  to  be  aftected  in  this  way.  Cysts 
thus  formed  have  been  styled  by  Virchow  cysts  by  retention.  But 
cystic  degeneration  is  bv  no  means  limited  to  such  structures.     It 


•  Op.  cit.,  p.  987.  2  Supplement  Cyc.  Anal,  and  Phys.,  p.  619. 


SYMPTOMS.  681 

may  occur  in  areolar  tissue  anywhere,  and  those  organs  which^ 
like  the  thyroid  and  mammary  glands,  are  prone  to  production  of 
new  growths  having  areolar  tissue  as  their  basis,  are  likewise 
especially  liable  to  it. 

It  is  believed  by  pathologists,  that  under  these  circumstances  the 
cyst  is  merely  an  expansion  of  the  areolae  of  the  areolar  tissue. 
In  various  parts  of  the  abdominal  cavity  such  cysts  are  found  under 
the  peritoneum  and  classed  under  the  head  of  sub[)eritoneal  cysts. 
Mr.  Satibrd  Lee  reports  one  case  of  a  tumor  which  tilled  the  abdo- 
men, and  destroyed  life,  after  having  lasted  for  twenty-five  years. 
On  post-mortem  inspection  a  large  cyst  was  found  behind  the  peri- 
toneum, which  had  originated  under  the  pancreas.  He  reports 
another  which  began  on  the  right  side  of  the  abdomen,  was  tapped 
forty-eight  times,  and  was  found  by  autopsj-  to  be  omental. 

Cysts  connected  with  the  Spinal  Cord. — In  K^ovember,  1870,  a 
woman  aged  36  years  entered  the  Woman's  Hospital  in  this  city 
and  came  under  the  care  of  Dr.  Emmet.^  He  found  a  large  cyst 
filling  the  hollow  of  the  sacrum  and  there  firmly  fixed.  To  aid  in 
diagnosis  an  ounce  of  fluid  was  drawn  ofi'by  aspiration.  This  was 
clear  and  limpid,  free  from  albumen,  and  revealed  under  the  micro- 
scope only  a  few  oil  globules.  The  patient  died,  and  Dr.  F.  Dela- 
field  on  making  an  autopsy  found  a  cyst,  which  contained  some  three 
quarts  of  fluid,  filling  completely  the  pelvic  cavity  and  extending 
up  to  a  level  with  the  second  lumbar  vertebra.  This  connniinieated 
with  the  spinal  cord  by  a  funnel-shaped  passage,  which  had  as  its 
lower  outlet  an  oval  opening  extending  from  the  upper  margin  of 
the  second  sacral  foramen  on  the  right  to  the  position  of  the  coccyx, 
which  was  wanting.  Over  the  surface  of  the  sac  was  a  network 
of  nerve  tissue,  extending  posteriorly  and  to  the  right  side.  The 
sac  was  supposed  to  be  one  of  spina-bifida  or  hydro rach is. 

Symptoms. — During  the  earlier  periods  of  the  development  of 
ovarian  cysts,  very  few  symptoms  ordinarily  show  themselves.  As 
enlargement  goes  on  the  patient  becomes  struck  by  the  fiict  that 
her  abdomen  has  increased  in  size,  and,  if  both  ovaries  be  aftected, 
menstruation  sometimes  ceases,  and  she  may  imagine  she  has  lie- 
come  pregnant.  Pressure  of  the  small  but  increasing  tumor  will 
sometimes  create  dragging  sensations  about  the  pelvis,  irritability 
of  the  bladder,  and,  if  the  growth  occupy  the  retro-uterine  spjice, 
as  it  often  does,  pain  in  the  back.     This  is,  however,  by  no  means 

'  This  case  is  described  in  the  Amer.  Journal  of  Obstetrics,  Feb.  1871. 


682  OVAEIAN    CYSTS. 

all  the  inconvenience  which  may  be  experienced.  A  small,  movable 
cyst,  which  may  be  pushed  about  in  the  abdomen,  will  sometimes 
cause  severe  pain.  In  one  sucli  case  which  I  saw  with  Dr.  Noeg^ 
gerath,  the  account  of  which  is  published  in  Dr.  Atlee's  work  on 
the  Ovaries,  ovariotomy  was  necessitated,  when  the  cyst  was  no 
larger  than  a  cocoanut,  by  excessive  pain. 

As  the  tumor  grows  and  tills  the  abdomen,  rising  above  the 
navel,  a  sense  of  distention  is  complained  of,  dyspnoea  begins  to 
show  itself  upon  exertion,  the  patient  feels  more  feeble  than  usual, 
and  slight  emaciation  is  observed.  As  it  increases  and  begins  to 
press  upon  the  large  viscera  beneath  the  diaphragm,  these  symptoms 
increase,  and  the  patient's  face  wears  a  peculiar  expression,  which 
has  been  styled  by  Mr.  Wells,  the  "facies  ovariana."  This  is 
created  by  an  absorption  of  adipose  tissue,  an  exaggeration  of  the 
natural  furrows  of  the  face,  and  an  expression  of  anxiety  and  ap- 
prehension. To  one  who  has  studied  this  expression,  an  imperfect 
description  such  as  this  will  recall  it ;  but  to  one  who  lias  not  be- 
come clinically  familiar  with  it,  it  is  impossible  to  convey  a  clear 
conception  of  it.  To  these  sym|)toms  the  mammary  and  gastric 
symptoms  of  pregnancy  sometimes,  though  rarely,  add  themselves. 

Pressure  ujjon  the  kidneys  creates  congestion  of  these  organs, 
and  scanty  secretion  is  a  common  result.  Occasional  attacks  of 
localized  peritonitis  are  by  no  means  rare,  and  hence,  in  many 
cases,  ascites  becomes  a  complication  of  the  affection. 

As  the  decadence  of  strength,  the  emaciation,  and  the  im])Over- 
ishment  of  the  blood  incident  to  tliis  grave  disorder  increase  with 
time,  digestive  and  intestinal  disorders  show  themselves,  anlema 
of  the  feet  and  legs  occurs,  great  feebleness  appears,  and  the  patient 
dies  from  progressive  exhaustion. 

A  summary  of  the  rational  signs  which  may  arise  in  consequence 
of  ovarian  cysts  from  the  commencement  of  their  growth  to  full 
development  may  thus  be  given:  irritability  of  the  bladder,  dys- 
menorrhoea,  constipation,  hemorrhoids,  pelvic  pains  of  neuralgic 
character,  symptoms  of  pregnancy,  scanty  urinary  secretion,  intes- 
tinal and  digestive  disorder,  deranged  respiratory  function,  pecu- 
liar facies,  emaciation,  cedema,  venous  distention  on  surface,  ascites, 
vomiting,  diarrhoea,  cardiac  irregularity,  aphthous  stomatitis,  and 
hectic.  In  cases  advanced  in  the  last  stage,  all  the  last  of  these 
may  show  themselves,  and  in  early  cases,  all  the  first  mentioned  : 
but,  in  many  instances,  some  of  the  most  prominent  of  these  sign.s 
are  entirely  wanting. 


PHYSICAL    SIGNS.  683 

Physical  Signs. — The  syuiiitoins  thus  far  enumerated  are  never 
sufficient  for  diagnosis.  They  are  usually  only  sufficient  to  suo-- 
gest  physical  examination,  by  which  reliable  signs  will  probably 
be  discovered,  and  the  diagnosis  be  made  complete. 

The  physical  signs  of  ovarian  cysts  are,  therefore,  of  the  greatest 
importance,  and  the  full  capacity  of  physical  exploration  should  in 
» \ery  case  be  developed,  for  to  it  we  must  look  for  answers  to  the 
following  questions : 

1st.  Does  a  tumor  exist? 
2d,    If  so,  is  it  ovarian  ? 

Does  a  tumor  exist? — To  decide  this  question,  the  patient  should 
be  placed  upon  her  back  upon  a  flat,  resisting  surface,  the  abdomen 
uncovered,  all  constriction  removed  from  the  waist,  and  the  knees 
drawn  up  so  as  to  relax  the  abdominal  muscles.  It  is  of  primary 
importance  that  she  should  be  calm,  and  give  herself  up  to  the 
examination  in  the  full  desire  of  aiding  the  physician  in  arriving 
at  a  diagnosis.  In  some  cases  the  patient,  from  nervousness,  in 
some  from  pain  created  by  })ressure,  and  in  others  from  a  desire  to 
mislead  and  deceive,  will  not  be  able  or  willing  to  do  this,  but,  by 
suddenly  contracting  the  abdominal  walls,  will  place  a  serious, 
perhaps  insurmountable,  obstacle  in  his  way.  Under  such  circum- 
stances ether  should  be  emploj^ed  as  an  anaesthetic,  and  full  investi- 
gation made.  The  abdominal  muscles  being  entirely  relaxed, 
careful  palpation  and  deep,  steady,  and  prolonged  pressure  sliould 
be  made  by  both  hands  over  the  whole  abdomen,  downwards 
towards  the  spine,  and  especially  over  the  pelvic  region.  By  this 
means  a  more  or  less  resisting  mass  may  be  discovered,  which  pro- 
duces an  abdominal  enlargement  visible  upon  inspection. 

Thus  far  very  little  has  been  learned  ;  merely  that  an  abnormal 
enlargement  exists  in  the  al)donien.  It  may  not  deserve  the  sig- 
nificant name  of  tumor,  but  be  due  to  one  of  these  states : 

1st.  Abnormal  thickness  of  abdominal  walls ; 

2d.    Tonic  spasm  of  abdominal  muscles  ; 

3d.    Intestinal  distention ; 

4th.  Distention  of  urinary  bladder; 

5  th.  Pregnancy. 

With  care  and  caution  each  of  these  conditions  may  nsunlly  bo 
eliminated  by  means  which  we  shall  soon  c-onsider.  A  neglect  of 
such  means  has  often  resulted  in  great  and  needless  alarm  to  pa- 


G8-4  OVARIAN    CYSTS. 

tieiits,  and  a  painfully  Imniiliating  and  often  ludicrous  exposure 
of  the  practitioner. 

It  havino"  been  now  decided  that  the  patient  has  an  abdominal 
tumor,  or,  in  other  words,  an  abdominal  swelling  due  to  a  morbific 
cause  of  serious  nature,  it  next  becomes  important  to  decide  whether 
it  be  ovarian  or  not. 

Is  the  tumor  ovarian? — It  has  been  already  stated  that  any 
abdominal  tumor  may,  unless  careful  means  of  differentiation  are 
adopted,  be  confounded  with  ovarian  growths.  The  truth  of  this 
will  be  appreciated  by  reference  to  the  valuable  tables  of  Dr.  John 
Clay,  the  translator  of  Kiwisch  on  the  Ovaries.  He  has  collected 
twenty-three  cases  of  attempted  ovariotomy  m  which  the  opera- 
tion was  abandoned  because  the  tumor  i)roved  not  to  be  ovarian. 
The  tumors  were  of  the  following  characters: 

12  were  uterine ; 

2     "  omental; 

2     "  results  of  chronic  peritonitis; 

2     "  not  discoverable  ; 

1  was  tubal  pregnancy  ; 

1     "  obesity ; 

1     "  mesenteric ; 

1     "  splenic ; 

1     "  not  stated. 

So  great  have  the  difficulties  of  diagnosis  thus  far  proved  that 
they  have  been  urged  by  tlie  opponents  of  the  operation  as  a  valid 
objection  to  it  as  a  surgical  procedure.  At  the  same  time  that 
they  are  acknowledged,  and  that  it  is  admitted  that  the  most  cau- 
tious and  skilful  diagnostician  may  be  defeated  by  them,  it  can  be 
confidently  asserted  that  every  year's  experience  greatly  diminishes 
them,  and  that  with  the  improved  means  now  at  command,  an 
experienced  examiner  will  rarely  be  misled.  Let  me,  however, 
again  insist  upon  the  fact  that  immunitj-  from  often  repeated 
errors  can  be  obtained,  even  by  such  an  one,  only  by  strict  adherence 
to  a  conscientious  and  exhaustive  examination  of  every  case,  a 
resort  to  all  the  known  means  of  diagnosis,  and  a  methodical  ex- 
clusion of  all  conditions  calculated  to  mislead. 

It  is  a  fact  which  I  daily  see  demonstrated  that  an  inexperienced 
diagnostician  usually  arrives  at  a  conclusion  by  the  application  of 
a  much  smaller  number  of  tests  than  a  veteran  examiner  would 
dare  to  do.  The  latter  has  been  so  often  deceived  that  he  knows 
his  weakness ;  the  former  has  yet  to  learn  it. 


PHYSICAL    SIGNS.  685 

The  means  of  physical  exploration  which  are  at  our  disposal  are 
the  following: 

Inspection  and  manipulation; 

Mensuration ; 
,  Palpation ; 

1  Percussion ; 

Auscultation; 

Vaginal  touch; 

Rectal  touch; 

The  uterine  sound; 

Aspiration  or  paracentesis; 

Chemical  and  microscopical   examination  of  fluids  of  the 
tumor; 

Explorative  incision. 

Solid  ovarian  tumors  are  rare  and  seldom  assume  very  large  pro- 
portions, and  although  ovariotomy  is  sometimes  demanded  for  their 
removal,  the  operation  is  specially  adapted  to  cystic  tumors.     We 
therefore  pass  to  the  more  careful  consideration  of  the  diagnosis  of 
these,  and  their  dilierentiation  from  other  abdominal  enlargements. 
An  ovarian  cyst  usually  develops  markedly  on  one  side  of  the 
abdomen,  and    if  multilocular   the   abdominal   distention   is   not 
symmetrical  even  in  advanced  periods.     As  it  increases  the  cyst 
pushes  the  intestines  aside  into  the  hypochondriac  regions.     The 
ascending  and  transverse  colon  alone  preserve  their  normal  posi- 
tions, and  the  omentum  majus  usually  covers  over  the  front  of  the 
j    tumor.     While  the  cyst  is  in  the  pelvis  the  uterus  usually  lies  in 
;    front  of  it,  but  as  increase  of  growth  occurs  it  is  ordinarily  pushed 
l)ehind  it.      There  are,  however,  excejitions  to  l)oth   these   state- 
ments.    In  rare  cases,  fortunately  for  the  ovariotomist,  a  portion 
of  intestine  runs  across  the  face  of  the  tumor,  being  tixed  there 
hy  adhesion.     The  uterus,  even  late  in  the  development  (^f  a  large 
cyst,  may  be  found   in  front  of  it  or  latero-flexed,  latero-verted, 
or  even  drawn  completely  above  the  pelvic  brim.     Curi(Mis  as  it 
may  api)ear,  great  diversity  of  statement  exists  concerning  tlie  rela- 
tion of  cyst  and  uterus  among  writers  on  this  subject.     "  Simpson's 
.   remark,"  says  Peaslee,^  "that,  'if  the  sound  show  a  tumor  in  front 
!  of  the  uterus,  the  disease  is  certainly  not  ovarian,'  is  incorrect. 
The  uterus  is  in  front  of  an  ovarian  tumor  only  in  exce]itional 
eases;  but  is  often  so  in  cases  of  uterine  fibroma  and  iibro-cyst. 

'  Op.  cit.,  p.  115. 


686  OVARIAN    CYSTS. 

Boinet  mentions  the  fact  as  a  remarkable  one  that  Cruveilliier 
found  the  uterus  heliind  an  ovarian  cyst  in  three  instances."  My 
observation  certainly  agrees  with  that  of  Dr.  Atlee,'  that  "the 
uterus  may  be  dragged  up,  or  tilted  up  out  of  the  pelvic  cavity  by 
the  tumor ;  or,  through  these  influences,  it  may  be  found  on  either 
side,  or  displaced  forward  or  backward  within  the  pelvis.  It  may 
also  be  crowded  downward  against  the  ]»erineum,  or  entirely  ex- 
truded through  the  vulvar  oriflce.  So  that  there  is  no  general  rule 
as  regards  the  position  of  the  uterus  in  ovarian  tumors." 

"When  the  tumor  has  ascended  above  the  umbilicus  as  the  patient 
lies  u[)on  the  back  the  abdomen  will  appear  rotund,  a  decided  pro- 
tuberance existing  and  very  little  flattening  out  by  sagging  of  fluid 
to  the  flanks  occurring.  As  the  hands  are  laid  upon  the  surface, 
and  manipulation  is  })ractised,  a  firm,  dense  mass  will  be  felt  which 
^delds  fluctuation,  not  usually  of  a  su[)erlicial  character  like  ascites, 
but  less  superficial  and  perceptible.  Percussion  will  yield  dulness 
all  over  the  surface  of  the  tumor  and  in  one  flank,  but  in  the  other 
resonance  will  generally  exist.  The  surface  of  the  tumor  will 
often  feel  irregular  and  lobulated,  and  in  multilocular  tumors  be 
more  voluminous  on  one  side  than  the  other.  If  pressure  be  made 
ujjon  the  tumor,  as  the  patient  lies  upon  the  back,  it  will  resist 
like  a  full  sac,  and  not  jneld,  and  the  pulsations  of  the  aorta  may 
be  felt  ol)scurely  through  it.  By  vaginal  and  rectal  touch  the  lower 
surface  of  the  tumor  may  be  felt  and  obscure  fluctuation  elicited. 

Mensuration  practised  from  the  umbilicus  to  the  sternum,  and 
the  umbilicus  to  the  anterior  superior  s])inous  processes  of  the  ileum, 
will  generally  show  a  marked  dift'erence  between  the  two  sides  in 
poly  cysts  and  less  diflerence  in  monocysts.  In  ascites  the  two  sides 
are  synmietrical.  Auscultation  serves  to  exclude  pregnancy.  By 
vaginal  touch  the  position  of  the  uterus  as  well  as  its  mol)ility  is 
ascertained,  and  when  combined  with  conjoined  manipulation  the 
solid  or  cystic  character  of  a  small  or  even  a  large  tumor  may  be 
determined  by  it.  Should  the  tumor  be  found  low  in  the  pelvis  in 
the  later  periods  of  growth,  it  is  prol)able  that  a  short  pedicle  exists, 
and  also  ]  .robably  adhesions.  Should  it  have  risen  out  of  the  pelvis 
the  pedicle  is  probably,  but  by  no  means  certainly,  a  long  one. 

The  uterine  sound  informs  us  as  to  the  capacity,  the  mobility,  and 
the  sensitiveness  of  the  uterus,  as  well  as,  to  a  limited  degree,  its 
relations  to  the  tumor. 

Simon's  method  of  rectal  exploration,  the  introduction  of  the 

'  Op.  cit.,  p.  46. 


PHYSICAL    SIGNS. 


087 


whole  hand,  and  if  necessary  of  the  forearm,  into  the  Ijowcl,  consti- 
tutes one  of  the  most  valuable  means  of  diagnosis  and  ditferentia- 
tion  at  our  command.  By  it  the  point  of  origin  of  the  tumor,  as 
well  as  its  general  characters,  may  be  very  accurately  ascertained. 

Emptying  the  cysts  of  the  tumor  of  fluid  by  aspiration  or  tai»ping 
is  likewise  a  most  useful  means  of  gaining  information;  and  of 
great  moment  is  the  careful  and  intelligent  examination  of  the 
fiuids  removed. 

Of  late  it  has  been  proposed  to  determine  as  to  the  nature  of  such 
fluid  by  the  discovery  in  it  of  ''  luteine,"  a  yellow  substance  found 
in  the  blood,  the  egg,  and  the  fluid  contents  of  ovarian  tumors. 
As  yet,  this  test  has  been  too  little  investigated  to  enable  us  to 
decide  what  weight  is  to  be  given  to  it. 

Lastly  we  reach  the  crucial  test  of  explorative  incision,  the  value 
of  whicii  cannot  be  exaggerated,  but  which  is  attended  by  con- 
sideral)le  danger. 

These  are  the  means  by  which  the  positive  signs  of  ovarian 
cystoma  may  be  elicited,  but  before  a  diagnosis  is  arrived  at  by 
deductions  based  upon  them,  many  other  abdominal  enlargements 
must  Ije  carefully  considered  and  excluded.  If  this  ])e  necessary 
merely  in  arriving  at  a  correct  diagnosis  where  no  operation  is  to 
be  practisc<l,  how  much  more  so  is  it  in  view  of  the  grave  procedure 
of  ovariotomy.  Any  one  of  the  following  conditions  may  mislead 
the  investigator,  and  each  of  them  must  be  in  turn  considered  by 
him  who  desires  to  do  his  full  duty  to  his  patient  and  himself. 


Abnormal   thickness   or   ten- 
sion of  abdominal  walls 


Distention  of  abdominal  vis- 
cera 


Fluid     accumulation    within 
the  peritoneum 


f  Obesity; 
j  Oedema; 
j   Elephantiasis; 
[  Tonic  spasm. 

Tympanites ; 

Fecal  tumor; 

Dilatation  of  stomach; 

Distended  bladder; 

ITomatometra ; 

Physometra ; 

Cystic  chorion; 

Hydrosalpinx. 

Ascites; 

Encysted  dropsy ; 

Hematocele; 

Colloid  accumulation. 


688 


OVARIAX    CYSTS. 


Cystic  disease  of  otiier  parts 
iu  the  abdoiuen 


Excessive  development  or  dis- 
placement of  otlicr  viscera  - 
of  the  abdomen 


Pres: 


gnancy 


Diseased  states  of  pelvic  walls 
and  areolar  tissue 


Cyst  of  broad  ligament ; 

Renal  cyst; 

S^tlenic  cyst ; 

Hepatic  cyst ; 

Parasitic  cyst ; 

Subperitoneal  cyst; 

Uterine  cyst; 

Uterine  cysto-tibroma. 

Uterine  fibroma; 

Enlarged  spleen; 

Enlarged  liver; 

Fibro-plastic  tumor  of  peritoneum ; 

Sarcoma  of  abdominal  glands; 

>ralignant  disease; 

Omental  tumor; 

Displaced  kidney ; 

Disj)laced  liver. 

Xormal ; 

(  Ventral ; 
Extra-uterine  -  Tubal 

(  Interstitial; 
With  amniotic  droj)sy; 
AVith  ovarian  dro[)sy; 
With  dead  child. 
Enchondroma; 
Encephaloid  of  bones; 
Pelvic  abscess. 


Abnormal  Thickness  or  Tension  of  AlMlorainal  Walls. — Obesity 
will  be  recognized  by  obscure  resonance  on  i)ercussioji  over  the 
whole  abdomen ;  by  absence  of  a  defined,  resisting  outline  to  the 
supposed  tumor;  by  the  possibility  of  catching  the  fatty  walls  be- 
tween the  two  hands,  lifting  them,  and  rolling  them  over  the  mus- 
cular floor  beneath  ;  by  the  deep  depression  which  can  be  made 
when  the  patient  is  anaesthetized;  and  by  the  pendulous  folds 
created  by  assumi)tion  of  the  sitting  posture.  It  would  be  inex- 
cusable in  an  expert  to  mistake  this  condition  for  ovarian  tumor, 
but  for  an  inexi)erienced  examiner  not  at  all  so.  I  see  numerous 
cases  every  year  in  which  such  an  error  is  conniiitted  by  very  com- 
petent practitioners. 

CEdema  will  be  known  by  pitting  upon  pressure;  by  the  exist- 
ence of  the  same  condition  in  the  areolar  tissue  of  the  feet  or  face; 
and  by  its  generally  attending  uremia,  chlorosis,  or  cardiac  disease. 


DISTENTION    OF    ABDOMINAL    VISCERA.  G89 

Elephantiasis,  of  which  Dr.  Atlee  records  a  remarkable  case, 
would  be  recognized  by  the  peculiar  structui-al  alterations  of  the 
skin  which  characterize  it. 

Tonic  spasm  of  the  abdominal  muscles  has  more  than  once  led, 
as  has  indeed  obesity,  to  abdominal  section  for  removal  of  a  tumor. 
It  often  occurs  under  the  name  of  "phantom  tumor"  in  very  hys- 
terical women,  and  is  not  rare  as  a  reflex  result  of  caries  of  the 
vortebr?e.  It  may  be  diagnosticated  by  resonance  on  percussion ; 
absence  of  fluctuation ;  and  absence  of  all  signs  of  tumor  under 
anaesthesia.  In  case  of  doubt,  anaesthesia  should  always  be  resorted 
to.  In  addition  to  these  signs,  the  unaltered  position  of  the 
uterus  constitutes  an  important  one. 

Distention  of  Abdominal  Viscera. — Even  without  abdominal 
spasm  a  large  amount  of  air  sometimes  accumulates  in  the  intes- 
tines from  hysteria,  digestive  disorder,  or  great  obstruction  in  the 
canal.  It  may  be  known  by  resonance  on  percussion ;  absence  of 
fluctuation ;  absence  of  all  signs  of  tumor  upon  examination  under 
anesthesia ;  and  the  normal  position  of  the  uterus.  By  firm, 
steady  pressure  downwards  towards  the  spine,  kept  up  and  in- 
creased after  each  expiration,  resistance  will  be  overcome,  and 
deep  exploration  prove  the  absence  of  a  tumor.  This  method  was 
systematized  by  Ro'derer. 

Fecal  tumor  will  be  marked  by  absence  of  fluctuation ;  a  pecu- 
liar "  doughy"  sensation  u}!on  manipulation:  pain  upon  pressure; 
constipation;  violent  colic;  and,  most  valuable  sign  of  all,  the 
creation  of  a  distinct  pit  or  depression  when  steady  pressure  is 
made  at  one  point,  the  patient  b^ing  an?Bsthetized.  The  action 
of  cathartics  and  enemata  is  often  entirely  delusive  as  a  test  of 
fecal  tumor. 

Dr.  Atlee  relates  a  case  of  distention  of  the  stomach  in  a  man,  in 
which  that  organ  filled  the  entire  abdominal  cavity,  and  covered, 
like  an  apron,  all  the  other  abdominal  organs.  "Had  the  patient 
l;)een  a  female,"  says  he,  "I  should  at  once  have  pronounced  it  an 
ovarian  cyst."  Explorative  incision  would  alone  have  accomplished 
diagnosis. 

It  may  be  thought  unlikely  that  a  distended  bladder  could  be 
mistaken  for  an  ovarian  cyst,  but  it  often  gives  the  appearances  of 
one.  In  one  case  in  which  this  difliculty  had  existed  for  three 
weeks,  I  found  tlie  bladder  distended  so  as  to  reach  above  the 
umbilicus,  its  neck  Ijeing  compressed  by  the  neck  of  a  rctroverted 
la-egnant  uterus.  Suspicion  as  to  the  nature  of  the  tumor  will  be 
excited  by  interference  with  urination,  constant  involuntary  dis- 
44 


690  OVAEIAN    CYSTS. 

chpTge  of  urine  taking  place,  and  the  very  frequent  concurrence, 
according  to  my  experience,  of  retroversion  of  the  pregnant  uterus. 
Sliould  aspiration  be  practised,  the  physical  and.  chemical  features 
of  the  urine  will  suggest  a  resort  to  the  catheter,  which  will  settle 
the  question  of  diagnosis. 

In  considering  the  difterentiation  of  hematometra,  physometra, 
and  cystic  degeneration  of  the  chorion,  little  reliance  should  be 
placed  upon  rational  signs  in  comparison  with  physical.  Cessation 
of  menstruation  and  many  of  the  other  signs  of  pregnancy  will  be 
discovered  in  most  cases,  and,  in  physometra  and  cystic  chorion, 
characteristic  discharges  will  usually  attend — air  in  the  former,  and 
bloody  serum  in  the  latter.  The  enlarged  uterus  will  be  recog- 
nized as  the  tumor  in  question  by  conjoined  manipulation  and 
Simon's  method ;  but  the  decisive  test  of  these  conditions  consists 
in  the  passage  of  the  uterine  sound,  or  of  a  silver  catheter  to  the 
fundus,  in  order  to  allow  of  escape  of  imprisoned  material,  which, 
being  collected,  may  be  submitted  to  chemical  and  microscopical 
examination. 

Hydrosalpinx  sometimes  develops  into  a  large  tumor.  De  Haen 
describes  one  which  weighed  seven  pounds.  To  differentiate  such 
a  condition  from  ovarian  cyst,  but  two  means  can  be  relied  upon : 
first,  the  removal  of  fluid,  and  examination  by  chemical  means  and 
the  microscope ;  and  second,  explorative  incision. 

Fluid  Peritoneal  Accumvlations. — It  is  often  exceedingly  difficult 
to  ditierentiate  between  ascites  and  ovarian  dropsy.  The  means 
which  ordinarily  enable  us  to  do  so  are  here  stated.  It  must,  how- 
ever, be  borne  in  mind  that  there  are  cases  in  which  even  the  most 
important  may  be  transposed.  For  example,  an  ovarian  ejfit 
sometimes  establishes  communication  with  the  intestines,  and  be- 
comes resonant ;  while,  in  ascites,  where  the  amount  of  fluid  is 
excessive  and  the  mesentery  short,  dulness  exists  over  the  front 
of  the  abdomen.  The  rule  is  here  adhered  to,  but  the  exceptions 
must  not  be  lost  sisfht  of. 


In  Ascites. 
1st.  The  enlarc^enieiit  will  have  shown 


In  Ovarian  Dropsy. 

1st.   A  small,  round  tumor  will  often 
have  shown  itself  in  the  beginning  in  one  f  no  small  tumor  at  any  point ; 
iliac  fossa ;  I 

2d.    In  supine  posture  a  rotundity  is  |      2d.  In  supine  posture  the  fluid  gravi- 


observed  in  the  abdomen ; 

3d.  Percussion  madp  in  supine  posture 
gives  dulness  over  surface  of  abdomen ; 


tales  to  sides  of  abdomen,  and  the  ab- 
dominal surface  is  flattened ; 

M.  Percussion  gives  resonance  over 
abdominal  surface  because  the  intestines 
float  on  the  fluid; 


FLUID    PERITONEAL    ACCUMULATIONS. 


691 


In  Ovarian  Dropsy. 

4th.  Change  of  posture  alters  area  of 
dulness  but  little ; 

5tli.  No  evidences  of  cardiac,  renal,  or 
hepatic  disease  exist  as  a  rule; 

6th.  Skin  is  normal  as  to  color,  mois- 
ture, etc. ; 

7th.  ffidema  of  the  feet  is  absent  until 
a  late  period,  when  the  patient  has  be- 
come exhausted ; 

8th.  Health  fails  slowly  ; 

9th.  Sitting  posture  affects  shape  of 
abdomen  but  little ; 

10th.  Fluctuation  ordinarily  not  so 
superficial,  level  fixed  to  great  extent, 
ceases  where  intestinal  resonance  begins ; 

11th.  Aortic  pulsation  transmitted ; 

12th.  Fluid  usually  amber  colored  and 
tenacious,  often  like  syrup,  of  various 
hues  in  polycysts,  not  spontaneously 
coagulable,  always  sticky  when  rubbed 
between  fingers.  Shows  cylindrical  epi- 
thelium, granular  cells  and  matter,  oil 
globules,  and  cholesterine,  and  contains 
paralbumen  and  metalbumen.  'I'lie  granu- 
lar cell  is  characteristic  and  distinguish- 
able from  other  cells  by  its  merely  be- 
coming transparent  by  acetic  acid  ;  others 
increase  in  size ;' 

Specific  gravity,  1.018  to  1.024. 


In  Ascites. 

4th.  Change  of  posture  alters  area  of 
dulness  markedly ; 

5th.  Evidences  of  cardiac,  renal,  or 
hepatic  disease  almost  always  exist ; 

6th.  Skin,  in  majority  of  cases,  gives 
evidences  of  cirrhosis  by  its  parchment 
feel  and  jaundiced  hue  ; 

7th.  Q:]dema  of  the  feet  exists  as  an 
early  sign ; 

8th.  Health  fails  early  and  rapidly ; 

9th.  Produces  bulging  below  and  often 
between  rectum  and  through  navel ; 

10th.  More  superficial,  level  changes 
with  change  of  posture,  perceived  even 
where  intestinal  resonance  exists. 

11th.  Not  so. 

12th.  Fluid  of  light  straw-color ;  spon- 
taneously coagulable  from  containing 
fibrin;  without  sedinientusually;  ishows  to 
microscope  squamous  epithelial  cells,  oil 
globules,  pus  cells,  and  amoeboid  bodies; 
does  not  contain  paralbumen,  metalbu- 
men. or  cholesterine ; 


Specific  gravity,  1.010  to  1.01.5. 


Sometimes,  however,  peritoneal  accumulations  are  sacculated  by- 
encompassing  lympli  in  one  portion  of  the  peritoneum ;  among  the 
intestines  matted  together  by  eftused  lymph;  or,  as  in  a  case 
recorded  l)y  West,  enveloped  by  the  omentum.  "Between  four 
and  five  quarts,"  says  he,  "  of  a  dark  fiuid  were  found  collected 
between  the  folds  of  the  peritoneum."  The  amount  of  fluid  thus 
imprisoned  is  often  very  large,  and  hence  the  difficulties  oY  diag- 
nosis which  have  led  Mr.  Wells^  to  assert,  "I  am  aware  of  no  nu'an.s 
by  which  such  cases  are  to  be  distinguished  from  ovarian  dr()]K><y." 
McDowell  himself  once  opened  an  abdomen  in  such  a  case  under 
the  belief  that  an  ovarian  tumor  existed.  Tlie  intestines  do  not 
rise  above  the  fluid  as  in  simple  ascites,  but  there  is  loss  rotundity 
to  the  mass,  and  less  interference  with  respiration  than  are  found 


Drysdale. 


*  Dis.  of  Ovaries,  p.  1.34. 


692  OVARIAN    CYSTS. 

to  exist  with  ovarian  cyst.  Diagnosis  in  these  difficult  cases  must 
depend  upon  the  results  of  aspiration,  examination  of  contained 
fluids,  Simon's  method,  and  explorative  incision. 

The  sudden  appearance  of  hematocele,  the  immediate  and  often 
urgent  symptoms  which  it  excites,  and  the  removal  of  a  little  fluid 
by  aspiration  will  settle  the  question  of  diagnosis. 

Colloid  disease  sometimes  afiects  the  wLole  peritoneal  cavity. 
In  some  cases  it  appears  to  escape  into  it  from  a  ruptured  ovarian 
cj^st;  in  others  it  originates  there.  Removal  of  a  small  amount  of 
the  characteristic  material  hy  tapping  is  the  only  means  of  diagnosis. 

Cystic  Disease  of  Otiier  Ivrts  in  iJte  Abdomen.- — Cysts  of  tlie  broad 
ligament  so  closely  resemble  unilocular  ovarian  cysts  as  to  be  diag- 
nosticable  only  by  explorative  incision  or  aspiration.  Their  cha- 
racter might  be  suspected  from  superficiality  of  fluctuation,  slight 
implication  of  general  health,  absence  of  emaciation,  and  slowness 
of  growth;  but  the  chemical  and  microscopical  features  of  the  con- 
tained fluid  would  alone  decide  positively.  This  fluid  is  as  clear 
and  pure  in  apj^earance  as  distilled  water,  showing  wbcn  boiled 
after  addition  of  acetic  acid  only  a  trace  of  albumen  as  an  albumi- 
nate, loaded  with  chloride  of  sodium,  and  containing  only  a  few  fat 
and  blood  globules.  After  evacuation  the  cyst  walls  cannot  be  felt, 
and  tapping  often  proves  curative.  Sjiiegelberg  removed  such  a 
cyst  in  18G9,  the  walls  of  which,  unlike  those  of  ovarian  tumors, 
contained  muscular  fibres  and  the  fluid  of  which  contained  albumen. 

Eenal  cysts  have  several  times  deceived  the  miost  skilful  diagnos- 
ticians. Their  characteristics  are  these:  they  ordinarily  push  the 
intestines  forwards  and  not  backwards;  pus,  blood,  and  albumen  usu- 
ally occur  in  the  urine;  these  tumors  grow  from  above  downwards; 
they  are  rare  and  grow  slowh*;  may  be  pushed  up  so  that  reso- 
nance occurs  between  tumor  and  pelvis;  and  the  fluid  contained 
shows  none  of  the  microscopical  features  of  ovarian  cyst,  while  it 
shows  the  chemical  and  microscopical  elements  of  urine.  Some- 
times ecliinococci,  which  are  frequent  in  renal  cysts  and  unknown 
in  ovarian,  are  found.  The  tumor  is  apt  to  be  crossed  by  the 
descending  colon  or  to  lie  outside  of  the  ascending  colon ;  it  is 
usually  marked  by  renal  and  not  by  menstrual  derangement;  and 
is  usually  unilateral. 

Sometimes,  however,  a  renal  cyst  occupies  a  median  position, 
extends  like  an  ovarian  tumor  into  the  pelvis;  is  attached  to  the 
pelvic  organs;  pushes  the  intestines  aside  like  an  ovarian  cj-st; 
contains  fluid  free  from  elements  of  urine,  and  even  presents  cboles- 
terine  and  paralbumen.     In  such  cases  the  determination  of  the 


CYSTIC    DISEASE    OF    OTHER    PARTS    IN    ABDOMEN.       693 

point  of  attaclimeiit  by  Simon's  method  constitutes  a  most  valu- 
able  resource. 

Splenic  and  hepatic  cysts  are  rare,  grow  from  above  downwards, 
give  an  area  of  duhiess  between  tumor  and  pelvis,  and  in  the  fluid 
of  the  latter  the  echinococcus  is  often  discovered.  In  both  Simon's 
method  is  of  great  value. 

Parasitic  cysts,  the  result  of  the  presence  of  the  echinococcus, 
may  develop  in  any  of  the  organs  or  tissues  of  the  abdomen.  Should 
the  position  of  the  tumor  be  such  as  to  lead  to  doubt  as  to  difteren- 
tiation  between  it  and  ovarian  cyst,  diagnosis  would  be  attainable 
only  by  aspiration  and  examination  by  the  microscope  and  chemi- 
cal means.     The  former  would  show  the  presence  of  the  parasite. 

Subperitoneal  cysts  are  distinguishable  from  ovarian  only  by 
physical  features  of  contained  fluid  and  explorative  incision. 

Cysts  growing  from  the  uterus  itself  are  not  common.  They  may 
be  recognized  by  Simon's  method,  by  the  chemical  examination  of 
their  contents,  and  by  the  curative  eftects  of  tapping.  Atlee  reports 
three  cases  thus  cured.  Furthermore  the  fluid  which  they  contain 
separates  into  a  coagulum  and  a  pinkish  or  bright  red  portion 
which  does  not  coagulate,  and  the  peculiar  cells  of  ovarian  fluid 
do  not  appear  in  it.     Ovarian  fluid  never  spontaneously  coagulates. 

Fibro-cystic  tumors  are  diflicult  of  differentiation  from  ovarian 
cystoma,  but  when  we  compare  our  present  position  with  reference 
to  this  subject  witl:^  what  it  was  only  a  few  years  ago  we  have 
great  cause  for  congratulation.  I  here  give  only  the  most  promi- 
nent differences  between  the  two  diseases,  and  hence  those  uj)on 
which  reliance  can  really  be  placed.  To  many  of  these  even,  how- 
ever, there  are  exceptions ;  to  several  there  are  none. 


Ovarian  Cyst. 
Grows  more  rapidly  and  is  less  governed 
by  age. 

Uterine  cavity  not  usually  enlarircd. 
Uterus  more  independent  of  tumor. 


Uterine  Fibro-cyst. 

Grows  slowly  and  occurs  usually  after 
thirty  years  of  age. 

Uterine  cavity  generally  enlarged. 

Connection  of  tumor  and  uterus  usually, 
tliongh  not  always,  intimate. 

Fluid  spontaneously  and  quickly  coagu- 
lates. 

Uterus  sometimes  lifted    above  pnhos 
.-ind  out  of  pelvis,  often  in  front  of  tumor. 

ITealth  remains  good  for  years.  j      Generally  fails  williin  three  years. 

Microscope  shows  fibre  ceil  (Drysdale).  |      .Sliows  the  peculiar  granular  and  opi- 

'  thelial  cells  of  ovarian  cyst. 

Althou2:h  these  si2:n8  are  all  of  some  value,  those  which  should 
.  be  regarded  as  most  reliable  are  the  following:  spontaneous  coagu- 


Never  does  so. 

Uterus  generally  behind  tumor. 


694  OVARIAN    CYSTS. 

lability  of  the  contained  fluid;  presence  of  the  fibre  cell;  increased 
capacity  of  the  uterus;  and  the  determination  of  its  connection 
with  the  tumor  by  means  of  Simon's  method  of  rectal  exploration. 
Explorative  incision  should  not  rank  high  as  a  diagnostic  method, 
for  simple  section  of  the  abdominal  walls  is  not  enough,  and  the 
exploration  which  is  further  required  to  decide  the  point  exposes 
the  patient  to  great  danger. 

Excessive  Development  or  JDisplaeement  of  other  Viscera. — If  ascites 
do  not  attend  hepatic  and  splenic  enlargement,  there  will  never  be 
any  great  difiiculty  in  distinguishing  them  from  ovarian  cystoma. 
Should  it  do  so,  tapping  should  be  resorted  to. 

Uterine  fibroma  may  be  recognized  by  its  peculiar  hardness,  slow- 
ness of  growth,  absence  of  fluctuation,  continuance  of  good  health 
and  absence  of  emaciation,  tendency  to  increased  menstrual  flow, 
irregular  surface,  intimate  connection  with  uterus,  increase  in 
capacity  of  this  organ,  and  absence  of  fluid  upon  aspiration  or 
tapping.  It  must  not  be  forgotten,  however,  that  the  uterus  may 
be  normal  in  size,  and  the  tumor  entirely  independent  of  it. 

"  The  symptoms  caused  by  the  growth  of  large,  fatty,  and  fibro- 
plastic tumors  from  various  parts  of  the  peritoneum  or  mesentery," 
says  Spencer  "Wells,'  "  so  much  resemble  those  of  true  ovarian  dis- 
ease, that  their  real  nature  can  only  be  determined  in  some  cases 
by  an  exploratory  incision  or  tapping."'  Should  fluid  be  removed 
from  them  it  would  lack  the  i)eculiar  ovarian  cellular  elements,  and 
would  spontaneously  coagulate,  and  Simon's  method  would  in  some 
cases  demonstrate  the  fact  that  the  point  of  origin  is  not  the  ovary. 

A  movable  or  floating  kidney  might  be  mistaken  for  an  ovarian 
cyst,  but  for  so  small  a  one  that  the  question  of  ovariotomy  would 
not  arise  in  connection  with  it.  Time  would  prove  that  it  was 
not  a  growing  ovarian  cyst. 

^Dr.  J.  K.  Dale,  of  Little  Rock,  Arkansas,  reports  an  interesting 
case  of  tumor  supposed  to  be  ovarian,  but  which  upon  explorative 
incision  was  found  to  be  the  liver,  which  was, "  free  and  movable, 
very  much  enlarged,  occupying  the  right  half  of  the  pelvis,  en- 
croaching upon  the  bladder  and  rectum,  and  interfering  very  mate- 
rially with  the  due  performance  of  their  respective  functions."  I 
have  myself  met  with  precisely  the  same  experience  in  a  case  in 
which  I  made  an  explorative  incision  in  New  Haven,  in  presence  . 
of  Drs.  "VVhittemore,  Jewett,  and  others. 

Pregnancy. — The  ordinary  signs  of  utero-gestation,  both  rational 


'  Op.  cit.,  p.  146.  ^  Richmond  and  Louisville  Med.  Journ.,  April,  1874. 


NORMAL  AND  ABNORMAL  PREGNANCY.        695 

and  physical,  slioukl  be  carefully  considered  in  eliminating  normal 
and  interstitial  pregnancy.  More  than  one  woman  has  died  from  the 
passage  of  a  trocar  and  canula  into  the  pregnant  uterus  after  abdom- 
inal incision,  an  accident  certainly  scarcely  more  deplorable  lor  the 
})atient  than  for  the  unfortunate  practitioner  whose  carelessness 
causes  it.  I  say  carelessness,  for  the  reason  that  the  passage  of  the 
uterine  sound  as  a  means  of  differentiation  would  always  prevent 
error.  True,  this  would  result  in  premature  labor  in  normal  preg- 
nane}', but  how  much  better  this,  even  at  the  sacrifice  of  the  child's 
life,  than  the  terrible  mishap  just  alluded  to. 

During  the  past  eighteen  months  three  cases  of  pregnancy  at  full 
term  have  been  referred  to  me  as  ovarian  cysts,  and  this  not  by 
ignorant  men  but  by  very  capable  practitioners.  Two  out  of  the 
three  pregnancies  were  illegitimate,  and  the  examiners  wore  misled 
by  relying  upon  rational  instead  of  physical  signs.  Reliance  should 
be  placed  especially  upon  discovery  of  the  fcetal  body  and  move- 
ments by  careful  palpation;  upon  ballottement  between  the  fifth 
and  seventh  months;  upon  recognition,  by  vaginal  touch,  of  the 
movable  presenting  part  after  that  time ;  and  upon  the  fatal  heart 
sounds  and  placental  bruit.  The  gastric,  mammary,  and  nervous 
symptoms  of  pregnancy  sometimes  result  from  ovarian  disease. 

Should  the  child  be  dead  many  of  these  symptoms  will  be  absent, 
and  if  it  be  retained  in  utero,  as  it  sometimes  is,  for  many  years, 
diagnosis  must  depend  upon  the  history  of  the  case,  Simon's  method, 
the  uterine  sound,  and  dilatation  of  the  cervix  so  as  to  admit  of 
digital  exploration.  In  tubal  or  ventral  pregnancy  diagnosis  would 
prove  more  difficult,  but  the  same  means  will  aid  in  making  it,  for 
even  when  the  fcetus  is  developed  out  of  the  uterus  that  organ  en- 
larges decidedly. 

Xot  only  should  a  differential  diagnosis  be  made  between  preg- 
nancy and  ovarian  tumor;  even  after  recognition  of  the  latter,  the 
former  should  always  be  eliminated  as  a  coincident  condition. 

Dropsy  of  the  amnion  gives  very  superficial  fluctuation,  and 
might  deceive  one  not  careful  in  diagnosis.  A  patient  investigation 
of  the  case,  and  consideration  of  its  history  would  ordinarily 
remove  all  doubt.  The  fibres  of  tlie  cervix  uteri  are  usually  ex- 
panded, the  cervix  moves  as  the  tumor  is  rolled  in  the  alxlomen, 
and  the  uterine  sound  passes  far  up  into  the  cavity  above.  Should 
aspiration  have  been  resorted  to,  the  fluid  removed  will  be  found 
to  present  the  following  features.  It  is  alkaline,  with  P]iecific 
gravity  1005  to  1010,  contains  albumen  but  no  fibrin,  and  presents 


696  OVAEIAN    CYSTS. 

to  the  microscope  epithelial  cells  and  oil  globules.  Meconium  and 
blood  alter  these  features. 

Diseased  States  of  Pelvic  Walls  and  Areolar  Tissue. — Enchondroma 
or  encephaloid  disease  of  the  pelvic  walls  is  hard,  free  from  fluctua- 
tion, and  firmly  fixed  and  united  to  the  part  from  which  it  grows. 
E-ectal  exploration  and  abdominal  palpation  will  prove  these  facts 
and  if  aspiration  be  attempted  the  absence  of  fluid  will  be  evidenced. 

Pelvic  abscess  usually  results  from  cellulitis,  which  presents 
marked  symptoms.  It  rarely  extends  to  tlie  umbilicus,  hardness 
will  be  felt  in  one  or  other  iliac  fossa,  it  is  fixed  in  the  pelvis,  and 
aspiration  gives  evidence  of  pus.  Excessive  pain  attends  it,  with 
throbbing  and  pain  down  one  thigh,  and  the  outline  of  the  mass  is 
obscure  and  unsatisfactory.  Tliere  is  often  a  tendency  to  point, 
there  is  pain  upon  pressure,  and  there  are  generally  chills  and  fever. 

In  the  early  days  of  ovariotomy,  -when  adhesions  were  regarded 
as  a  bar  to  extirpation  of  these  tumors,  the  question  of  the  exist- 
ence of  adhesions  possessed  important  bearings.  Kow,  however, 
when  even  the  firmest  attachments  are  broken  not  only  with  im- 
punity, but  with  results  which  are  often  better  than  those  which 
follow  the  removal  of  a  tumor  from  a  healthy  peritoneum,  it  sinks 
into  comiDarative  insignificance.  This  is  a  most  fortunate  fact,  for 
the  reason  that  the  determination  of  the  existence  of  adhesions  is 
little  more  than  guess-work.  Beyond  a  few  very  general  facts  by 
which  we  may  venture  to  form  a  surmise,  all  is  empirical  predic- 
tion with  reference  to  the  matter. 

If  the  case  have  developed  very  rapidly  and  be  believed  to  be 
unilocular,  there  are  probably  no  adhesions. 

If  there  have  been  synij)tom8  of  peritonitis,  there  are  probably 
adhesions.     If  the  case  have  been  painless,  there  are  probably  none. 

Should  the  abdominal  walls  roll  freely  over  the  tumor,  the  patient 
lying  upon  her  back,  and  should  the  tumor  fall  low  in  the  abdomen 
as  she  suddenly  sits  up,  there  are  probably  no  anterior  adhesions. 
But  posterior  ones  may  exist  and  not  be  suspected  from  this 
examination. 

If,  upon  vaginal  examination,  the  uterus  and  base  of  the  tumor 
exhibit  immobility  such  as  is  found  in  pelvic  peritonitis,  and  if, 
upon  change  of  posture  from  erect  to  supine,  these  parts  do  not 
retreat  from  the  finger  in  the  vagina,  there  are  in  all  probability 
strong  pelvic  adhesions. 

All  these  signs  are  unreliable,  and  disappointment  will  surely 
follow  any  great  degree  of  confidence  which  is  reposed  in  them, 


FLUID    TUMORS.  697 

but  a  compensation  is  to  be  found  in  the  fact  already  stated  that 
even  linn  adhesions  do  not  contraindicate  removal. 

It  is  always  desirable  to  know  the  length  of  the  pedicle.  This 
point  can  be  approximatively  settled  in  a  certain  number  of  cases, 
by  the  means  recommended  by  Tixier^  of  Strasbourg.     lie  says : 

"Practice  and  observation  have  enabled  us  to  diagnose,  in  certain 
cases,  the  probable  length  and  variety  of  the  pedicle.  Certain  ol^jective 
and  subjective  signs  may  guide  the  practitioner  and  facilitate  his  diag- 
nosis; a  very  important  matter,  since  on  the  length  of  the  pedicle  often 
depends  the  success  of  Ihe  operation. 

"  We  have  hitherto  been  able  to  diagnose  with  almost  perfect  certainty 
three  varieties:  the  long,  short,  and  twisted  pedicle. 

"  The  long  pedicle. — The  form  of  tlie  abdomen  has  a  peculiar  aspect ; 
this  is  the  form  en  besace.  The  hjpogastric  portion  of  the  abdominal 
wall  is  applied  to  the  internal  surfaces  of  the  thighs,  and  the  ovarian 
tumor,  forcibl}^  projected  forwards,  seems  to  be  removed  from  the  supe- 
rior entrance  of  the  pelvis.  A  vaginal  examination  reveals  an  elevation 
of  the  cervix  uteri,  and  the  index  finger  passed  into  the  pelvic  excavation 
does  not  meet  with  the  tumor  at  any  point.  The  womb  is  very  movable 
and  can  be  readily  displaced.  The  collection  of  these  s^-niptoms  induces 
one  to  presume  that  there  is  an  elongated  condition  of  the  broad  ligament 
and  of  the  Fallopian  tube,  a  condition  favorable  for  forcing  the  i)edicle 
without  the  abdominal  wound. 

"  The  iihort  pedicle. — The  existence  of  the  short  pedicle  ma}^  be  as- 
sumed in  the  presence  of  the  following  symptoms:  in  the  first  place,  the 
form  of  the  abdomen  differs  from  that  described  above  ;  one  may  observe 
a  lateral  extension  without  pronounced  prominence  of  the  median  por- 
tion. In  attempting  to  introduce  the  tip  of  the  finger  between  the  tumor 
and  the  pubes,  one  feels  through  the  skin  that  the  growth  passes  into 
the  pelvic  excavation ;  its  base  seems  to  be  seated  over  the  pelvic  open- 
ing. The  vaginal  touch  denotes  a  sinking  of  the  cervix  uteri,  and  a  more 
or  less  pronounced  immobility  of  the  womb.  If  the  pelvic  excavation 
he  then  explored  with  the  finger,  one  feels  that  it  is  not  free,  and  that 
certain  parts  of  the  tumor  are  contained  within  it.  In  the  presence  of 
these  fiicts  the  surgeon  may  assume  that  there  is  a  greater  or  less  degree 
of  shortening  of  the  pedicle. 

'*  The  Iwided  pedicle. — At  first  sight  this  torsion  seems  difTioult  to 
determine.  It  may,  however,  under  certain  conditions  be  diagnosed  with 
greater  certainty  than  the  two  preceding  varieties.  Its  existence  may 
be  concluded  whenever  the  following  symptoms  have  been  ol)served: 

"  The    patients   experience   at    intervals   very  acute   pains   radiating 


'  Le  Pedicule  et  son  Traitemcnt  apr^s  I'Operation  de  rOvariotomie,  Strasbourg, 
1869;  Arcliivos  Generales  de  Medecine,  Juillet,  1870. 


698  OVARIAN    CYSTS. 

downwards  along  the  vein  corresponding  to  the  affected  ovary,  and  up- 
wards to  the  lumbar  region  on  the  same  side.  These  pains  are  excited 
by  work  and  fatigue.  They  break  out  also  when  the  patient  is  in  bed, 
and  when  she  wishes  to  change  her  position.  One  hears  also  from  these 
patients  of  very  strong  nterine  cramps  analogous  to  those  occasioned  by 
deligation  of  the  pedicle.  The  cystic  fluid  is  more  or  less  deep  in  color, 
presenting  a  hemorrhagic  appearance.  The  touch  in  these  cases  gives  no 
precise  indication.  One  can  only  acquire  the  idea  of  the  existence  of  an 
habituall}^  long  and  thin  pedicle  in  cases  of  this  kind." 

Although  I  have  not  been  ahle  to  draw  as  positive  and  certain 
conclusions  in  reference  to  the  determination  of  the  length  and 
character  of  the  pedicle,  by  aid  of  these  means,  as  M.  Tixier  has,  I 
nevertheless  regard  his  suggestions  as  valuable,  and  well  worthy 
of  application  to  every  case  in  which  ovariotomy  is  contemplated. 
One  rule  which  I  have  found  very  reliable  is  this — if  the  tumor 
be  found  far  up,  out  of  the  pelvis,  upon  vaginal  examination  the 
pedicle  cannot  be  very  short.  If  a  tumor  which  is  not  very  large 
be  fixed  in  the  pelvis  so  that  it  cannot  be  pushed  out,  the  pedicle 
Is  probably  a  short  one.  The  value  of  this  sign  may  be  increased 
by  examining  in  the  knee-elbow  position. 

When  doubts  exist  upon  any  of  the  points  here  stated,  which 
cannot  be  removed  by  those  means  of  investigation  which  are 
limited  by  the  abdominal  walls  and  pelvic  roof;  which,  in  other 
words,  extend  to,  but  not  be^^'ond,  the  peritoneum  in  their  immeduite 
application,  there  exist  three  methods  of  exploration  which  bring 
the  explorer  into  direct  contact  with  the  interior  of  the  abdomen 
and  of  the  tumor.  Those  positive  and  reliable  means,  which  may 
justly  be  styled  the  crucial  tests  of  abdominal  tumors,  are  the  fol- 
lowing : 

Aspiration ; 
Tapping ; 
Explorative  incision. 

To  these  a  certain  amount  of  danger  undoubtedly  attaches;  but 
when  compared  with  the  great  danger  arising  from  operation  upon 
an  uncertain  diagnosis,  it  becomes  trivial.  Many  an  ina])propriate 
case  has  been  submitted  to  the  operation  of  ovariotomy  which 
would  have  been  spared  it,  with  the  promise  of  a  prolongation  of 
life,  had  one  of  these  methods  been  previously  employed.  They 
are  of  course  not  to  be  confined  to  the  determination  of  the  cha- 
racter of  a  tumor  alone,  but  that  of  the  origin,  attachments,  and 
complications  of  any  abdominal  growth. 

The   introduction  of  aspiration  into  use  for  the   diagnosis   of 


FLUID    TUMORS.  699 

ovarian  tumors  constitutes  a  decided  advance.  The  instrument 
generally  employed  in  tliis  country  is  that  of  Dieulalby,  shown  on 
page  84.  By  this  a  delicate  hollow  needle  is  passed  into  the  tumor, 
and  pow-erful  suction  applied  through  an  India-ruhher  tuhe  con- 
nected with  a  strong  syringe,  in  which  a  vacuum  is  created  by 
an  upward  movement  of  the  piston.  Through  the  most  delicate 
needle  clear  fluids  will  pass,  and  through  the  largest,  which  is  very 
small  when  compared  with  an  ordinary  trocar  and  caimla,  very 
tenacious  colloid  material  may  be  drawn.  By  this  beautiful  in- 
strument a  large  polycystic  tumor  filled  with  tenacious,  syrupy 
fluid  may  be  readily  emptied  by  turning  the  needle  into  new  cysts 
as  those  first  punctured  are  evacuated.  And  w^hen  complete  evacu- 
ation is  not  desired,  it  furnishes  a  supply  of  fluid  for  chemical 
and  microscopical  examination.  It  greatly  diminishes  the  dangers 
of  such  evacuation  as  compared  with  those  resulting  from  tapping. 
The  dangers  attending  that  operation  are  the  following:  1st, 
hemorrhage  from  a  bloodvessel  in  the  abdominal  or  cyst  wall ;  2d, 
admission  of  air  to  the  cavity  of  the  sac  and  decomposition  of 
fluid,  which  may  create  inflammation  of  the  cyst  wall  and  septi- 
csemia;  3d,  subsequent  escape  of  the  contents  of  the  tumor  into  the 
peritoneum;  and  4th,  fatal  injury  from  wounding  of  an  intestine 
or  solid  organ.  Spencer  Wells  mentions  a  case  in  which  an  ac- 
quaintance of  his  tapped  a  patient  who  died  soon  after.  Upon 
autopsy  two  and  a  half  quarts  of  blood,  which  had  escaped  from  a 
wounded  varicose  vein,  were  found  in  the  peritoneal  cavity.  All 
these  dangers  are  considerable  from  ordinary  tapping;  decidedly 
less  so  from  aspiration. 

It  may  then  safely  be  said  that  aspiration  accomplishes  all  that 
tapping  does,  at  infinitely  less  risk,  and  that  the  former  should, 
when  practicable,  always  be  preferred  to  the  latter  procedure. 
Unfortunately,  the  cost  of  the  aspirator  is  large,  and  it  may  not  be 
attainable.  When  it  is  desired  merely  to  obtain  a  small  amount 
of  fluid  for  examination,  the  hypodermic  syringe  may  be  employed, 
even  in  preference  to  the  aspirator.  The  use  of  this  instrnment, 
which  was  suggested  by  Dr.  H.  F.  Walker  and  practised  by  myself 
before  our  knowledge  of  that  just  described,  consists  simply  in 
plunging  the  needle  with  syringe  attached  through  the  abdominal 
walls  at  difterent  points,  drawdng  out  as  much  fluid  as  ])ossil)le,  and 
expelling  this  into  a  test-tube  for  examination.  This  method  serves 
to  determine  the  following  points:  1st,  whether  a  tumor  is  llnid 
or  solid;  2d,  whether  it  contains  clear,  slightly  album inons  llnid 
or  ichorous  and  irritating  material;  3d,  by  means  of  several  punc- 


700  OVAEIAN    CYSTS. 

tures,  wliether  it  be  multilocular  or  not.  I  have  resorted  to  it 
many  times,  and  have  never  yet  seen  inflammation  result  from  it. 
In  one  case  which  I  saw  in  consultation  with  Dr.  Peaslee  he  drew 
ofl:'  by  the  hypodermic  syringe  for  examination  a  clear,  albuminous 
fluid,  and  decided  to  operate  by  ovariotomy  in  a  few  days.  Upon 
proceeding  to  do  so  the  sac  was  found  to  have  emptied  itself  into 
the  peritoneum  through  this  small  opening. 

Tapping  is  a  means  of  great  value  in  the  diagnosis  of  ovarian 
cysts  and,  where  the  aspirator  is  not  attainable,  should  never  be 
lightly  disregarded.  Atlce,  Wells,  Peaslee,  Spiegelberg,  and  many 
other  leading  ovariotomists  of  our  day  place  great  stress  upon  its 
value,  and  although  some,  like  Stilling,  have  entitled  it,  in  the 
warmth  of  deprecation,  "  a  crime,"  it  may  safely  be  said  to  have 
overcome  the  greater  part  of  the  objections  once  urged  against  it, 
and  to  have  fully  established  its  claim  to  consideration  as  a  valuable 
diagnostic  and  palliative  measure.  Wells^  has  proved  that  it 
does  not  considerably  increase  the  mortality  of  ovariotomy.  It  is 
often  even  an  excellent  preparation  for  that  operation,  and,  when 
practised  with  proper  precautions,  its  dangers  are  greatly  diminished. 
It  must  not  be  forgotten,  however,  that  it  is  attended  by  dangers, 
which  are  not  matters  of  speculation  but  of  fact  established  by 
statistical  evidence.  Of  130  instances  of  first  tappings  analyzed  by 
Kiwisch,  17  per  cent,  of  the  cases  died  within  a  few  hours  or  days 
after  the  operation.^  This  is  certainly  a  mortality  to  be  greatly 
dreaded,  especially  when  the  operative  procedure  which  induces  it 
is  not  curative,  but  one  resorted  to  merely  for  palliation  or  the 
accomplishment  of  diagnosis. 

Of  all  the  means  for  definite  and  certain  settlement  of  the  ques- 
tion of  diagnosis  in  abdominal  tumors,  I  esteem  explorative  incision 
most  highly.  As,  however,  it  involves  not  only  opening  the  peri- 
toneal cavity,  but  usually  considerable  manij)ulation  of  its  contents, 
it  necessarily  involves  a  certain  amount  of  danger.  While  the 
other  methods  may  be  practised  several  days  or  even  weeks  l)efore 
the  operation  of  ovariotomy,  this  should  constitute,  or  rather  be 
merged  into,  its  first  step.  If  it  yield  information  which  makes 
the  surgeon  decide  against  operation,  the  opening  made  should  be 
closed ;  if  the  light  which  it  throws  upon  diagnosis  favors  the 
radical  procedure,  the  incision  should  be  at  once  enlarged  and  pro- 
longed into  the  final  abdominal  opening. 

Explorative  incision  should  be  thus  performed.      The  patient 

'  Op.  cit..  p.  275.  2  Hewitt,  op.  cit.,  p.  637, 


TREATMENT.  701 

having  been  prepared  for  the  procedure  exactly  as  if  we  had 
determined  upon  ovariotomy,  she  is  placed  upon  the  table  and  sur- 
rounded by  assistants,  etc.,  as  in  the  case  of  the  radical  operation. 
An  incision  is  then  made  by  the  bistoury  upon  the  median  line, 
one  inch  in  length.  This  is  carried  down  to  the  tumor  and  the 
linger  is  at  once  gently  swept  over  this  in  every  direction,  so  as  to 
ascertain  its  character.  The  tumor  may  be  emptied  with  a  very 
small  trocar,  so  small  that  the  opening  made  may  be  readily  closed 
if  it  be  deemed  best  to  desist  from  radical  operation,  or  by  the  as- 
pirator. If  the  sac  be  emptied  by  this  means,  the  hand  is  then 
passed  into  the  abdominal  cavity  and  complete  exploration  made. 
If  it  be  not  completely  emptied,  a  sound  should  be  passed  into  the 
uterus  and  two  fingers  carried  down  through  the  aljdominal  open- 
ing to  the  fundus  uteri,  to  ascertain  as  accurately  as  jiossilde  the 
origin  and  attachments  of  tlie  solid  mass.  In  case  abdominal  effu- 
sion luive  existed,  this  of  course  at  once  flows  away,  and  any  growth 
existing  in  the  abdomen  comes  within  the  reach  of  the  finger. 

Before  leaving  this  part  of  my  subject  let  me  lay  betore  the 
reader  a  few  rules,  the  observance  of  which  will  diminish  very 
greatly  the  chances  of  his  falling  into  errors  of  diagnosis  in  operat- 
ing for  ovarian  tumors. 

1st.  Never  peiibrm  ovariotomy  without  carefully  exploring  the 
uterus  by  the  sound. 

2d.  Before  operation  always  remove  a  small  amount  of  fluid  by 
the  hypodermic  syringe  for  chemical  and  microscoj)ical  examina- 
tion. 

3d.  If  any  doubt  whatever  exist  as  to  diagnosis,  anaesthetize  the 
patient  and  employ  Simon's  method. 

4th.  If  doubt  still  exist,  empty  the  cyst  or  cysts  by  aspiration  or 
tapping. 

5th.  Should  all  doubts  not  be  cleared  up  at  the  moment  of 
operation,  begin  it  as  an  exjtlorative  incision  and  proceed  or  not  as 
instructed  l)y  what  is  discovered. 

Treatment. — The  medical  treatment  of  ovarian  dropsy  by  diu- 
retics, hydragogue  cathartics,  diaphoretics,  mercurials,  absorbents, 
mineral  waters,  etc.,  has  now  been  faithfully  tested  and  found  to  lie 
inefficacious.  After  a  careful  search  through  the  records  of  the 
subject,  one  is  forced  to  the  conclusion  that  an  extremely  small 
number  of  cases  exists  substantiating  the  possibility  of  the  accom- 
plishment of  absorption  by  these  means.  All  that  can  be  antici[)ated 
in  these  cases  from  medication  is  sustaining  the  nervous  and  san- 
guineous  systems  by  tonics  and  stimulants;  regulating  disordered 


702  OVARIAN    CYSTS. 

functions  by  diaplioretics,  catliartics,  diuretics,  and  anti-emetics ; 
and  relieving  local  inflammations  by  the  ordinary  means  usually 
resorted  to  under  sucli  circumstances.  I  am  the  more  urgent  in 
insisting  upon  the  fact  of  the  inefficacy  of  constitutional  treatment, 
because  I  rarely  meet  with  a  fully  developed  case  of  ovarian  dropsy 
at  my  clinique  which  does  not  bear  evidence  of  a  variety  of  attempts 
by  cupping,  leeching,  blistering,  inunction,  painting  with  iodine, 
and  correspondingly  active  internal  treatment,  to  dissipate  the 
accumulation.  There  is  but  meagre  proof  extant  that  such  means 
have  effected  cures,  and  there  is  nothing  more  certain  than  that 
they  lower  the  tone  of  the  system  and  depreciate  the  vital  forces. 
A  recoo;nition  of  this  fact  led  Dr.  W.  Hunter,  before  the  introduc- 
tion into  practice  of  the  present  methods  of  surgical  treatment,  to 
say  that,  "the  patient  will  liave  the  best  chance  of  living  long  under 
it,  ovarian  dropsy,  who  docs  tlie  least  to  get  rid  of  it." 

It  is  to  surgery  that  we  must  look  for  aid,  and  the  following 
list  represents  the  means  at  our  command.  It  does  not  by  any 
means  re[)resent  all  the  measures  which  have  been  proposed  and 
practised,  for  such  a  list  would  encumber  the  mind  of  the  reader 
with  much  that  would  be  of  no  practical  importance.  Only  those 
methods  are  recorded  which  are  to-day  regarded  as  well  established 
procedures : 

Tapping; 

Drainage; 

Incision ; 

Injection  of  the  sac ; 

Ovariotomy. 

Tapping. — The  operation  of  paracentesis,  or  tapping,  consists  of 
the  introduction  of  a  trocar  and  canula  through  the  walls  of  a  sac 
containing  fluid,  and  allowing  this  to  flow  away.  Of  all  the  opera- 
tions for  relief  of  ovarian  dropsy  this  is  the  oldest,  and  the  one 
most  frequently  performed.  The  advantages  which  it  offers  are, 
facility  of  performance,  quickness  of  relief,  and  immunity,  to  a 
certain  extent,  from  the  dangers  which  attend  more  radical  pro- 
cedures adopted  in  these  cases. 

It  is,  however,  attended  by  serious  disadvantages,  and,  although 
in  a  limited  number  of  cases  it  has  been  declared  to  have  proved 
curative,  it  should  never  be  practised  with  any  reliance  upon  its 
doing  so,  for  doubt  exists  as  to  the  authenticity  of  the  facts.  Fur- 
thermore, it  is  attended  l)y  the  immediate  dangers  recently  men- 
tioned, and  by  the  more  remote  one  of  exhausting  discharge  from 


TAPPING.  703 

the  sac  which  may  continue  so  long  as  to  wear  out  the  patient's 
strengtli.  M.  Courty  collates  one  hundred  and  thirty  cases  treated 
in  this  way  by  Kiwisch,  Lee,  and  Southam,  of  which  these  are  the 
results : 

46  died  after  the  1st  tapping. 

10  "         "       2d 

26         "         "       3d  to  6th  tapping. 
15        "        "       7th  to  12th    " 
13         "         "       12th  tapping. 

Of  20  of  these  cases  by  Mr.  Southam,  4  died  within  a  few  hours 
after  the  operation,  3  within  the  first  month,  and  14  within  nine 
months.  Kiwisch  lost  9  out  of  64  within  twenty-four  hours  after 
the  first  tapping.  Dr.  Fock,*  of  Berlin,  gives  the  following  table, 
displaying  the  dates  at  which  death  occurred  after  first  operations 
in  132  patients: 

25  died  within  a  few  days. 

24    "         "       G  months. 

22    "         "      12      •' 

21    "         "      24      " 

11  "         "      36      " 

29  only  were  alive  at  end  of  last  date. 

132 

It  will  thus  be  seen  that  reliable  statistical  evidence  places  this 
procedure  in  the  position  of  a  palliative  measure  which  is  generally 
followed  by  advance  of  the  disease,  and  not  rarely  by  immediate 
evil  results.  Still  it  must  not  be  lost  sight  of  that  death  may  be 
warded  ofl:'  by  the  operation,  many  existing  evils  alleviated  through 
the  course  of  a  period,  varying  from  ten  to  twenty-five  years,  and 
that,  in  a  few  cases,  complete  cure  may  have  been  effected.  Dr.  Eams- 
Ijotham  records  an  instance  in  which  one  hundred  and  twenty-nine 
tappings  were  performed  in  eight  years,  and  four  hundred  and 
sixty-one  gallons  of  fluid  removed ;  and  Dr.  Martineau  another, 
in  which  eighty  operations  evacuated  in  twenty-five  years  seven 
liundred  and  twenty-nine  gallons.  I  have  now  under  my  care  a 
patient  who  for  five  years  has  had  a  large  cyst  which  has  been 
tapped  forty-five  times. 

I  have  stated  that  a  considerable  number  of  cases  are  on  record 
in  which  it  is  asserted  that  simple  tapping  has  cured  ovarian  cys- 
toma. It  is  a  matter  of  great  doubt  whether  the  cases  tlius  cured 
were  true  ovarian  cysts,  or  cysts  of  the  Inroad  ligament,  wliicli  are 
often  thus  cured.    Knowing  of  no  well  authenticated  case  in  which 


'  Simpson,  op.  cit.,  p.  347. 


704  OVARIAN    CYSTS. 

ovarian  cyst  has  been  tlius  permanently  cured,  we  are  not  war- 
ranted in  regarding  this  measure  as  anything  more  than  a  valuable 
diagnostic  means  and  a  palliative  resource,  which  often  saves  life 
when  it  is  threatened  by  one  of  the  consequences  of  the  cystic 
disease. 

In  case  the  contents  of  the  cyst  do  not  appear  to  be  those  of  true 
ovarian  cystoma,  Imt  present  the  characters  of  the  fluid  of  cyst  of 
the  broad  ligament,  tapi)ing  may  be  practised  with  a  reasonable 
hope  of  curative  results. 

The  circumstances  which  ordinarily  indicate  the  propriety  of 
paracentesis  as  a  imlliative  measure  are,  rapid  accumulation  which 
interferes  with  some  important  function ;  coexistence  of  ovarian 
disease  with  pregnancy  ;  solitary  character  of  the  cyst ;  firm  adhe- 
sions which  bind  the  tumor  down  so  as  to  prohibit  a  more  radical 
procedure;  great  doubt  as  to  diagnosis  ;  or  constitutional  deljility, 
which  prevents  the  tolerance  of  a  more  serious  ojjcration.  The 
operation  may  be  performed  through  the  abdominal,  vaginal,  or 
rectal  wall. 

Tapping  throiKjlt  tlie  ahdominal  icall. — The  patient  being  placed 
upon  the  side,  a  many-tailed  bandage,  such  as  is  emplojx'd  in  para- 
centesis abdominis,  is  passed  around  the  body.  Its  ends  being 
held  by  assistants,  traction  upon  them  makes  firm  pressure,  evacu- 
ates the  tumor,  and  prevents  syncope.  A  fold  of  skin  being  now 
]tinched  up  Ix'twecn  two  fingers,  it  is  jicnetrated  by  a  lancet  or 
l>istoury  U[ton  the  linea  alba,  midway  between  the  symphysis  pul»is 
and  umbilicus.     The  trocar  and  canula  are  then  plunged  through 


Fig.  1 


Fig.  178. 


the  two  layers  of  peritoneum  and  the  wall  of  the  cyst.  Through 
the  canula  thus  introduced  a  flow  of  fluid  will  take  place,  which, 
if  such  an  instrument  as  that  represented  in  Fig.  177  be  employed, 
will  be  conducted  by  an  India-rubber  tulie  attached  to  the  cannhi 
into  a  tub  placed  Ijy  the  side  of  the  bed  upon  which  the  jiatient 


TAPPING    THROUGH    THE    WALL    OF    THE    VAGIXA.       705 

lies.     The  free  extremity  of  this  tube  is  kept  carefully  immersed 
in  water  in  the  tul),  to  prevent  entrance  of  air  into  the  sac. 

Should  other  cysts  be  felt  through  the  abdominal  wall  after 
emptying  the  main  one,  the  canula  may  be  made  to  empty  them, 
by  pressing  it  firmly  against  them. 

The  following  rules  should  be  observed  in  abdominal  tapping  of 
ovarian  cysts.  It  is  highly  probable  that  a  strict  adherence  to 
them  would  very  favorably  affect  the  statistics  of  the  operation. 

1st.  Never  tap  while  the  patient  sits,  but  always  as  she  lies  upon 
the  side  or  back. 

2d.  Cut  the  skin  with  a  lancet,  and  employ  a  trocar  and  canula, 
with  tube  immersed  in  water,  so  as  to  prevent  entrance  of  air. 

3d.  When  the  fluid  withdrawn  is  viscid,  always  wash  out  the 
cavity  of  the  sac  with  warm,  carbolized  water. 

4th.  Should  there  be  oozing  of  blood  from  the  puncture,  pass  a 
harelip  pin  deeply  through  its  lips,  and  affix  a  figure-eight  ligature. 

5th.  Keep  the  patient  recumbent  and  very  quiet  for  two  or  three 
days. 

Tappivg  iJtrough  (he  wall  of  the  vagina. — This  operation  has  been 
more  or  less  in  vogue  for  a  long  time.     According  to  Kiwisch, 
it  was  first  performed  by  Callisen  in  1775,  but  has  received  little 
notice  until  modern  times.     Velpeau^  declares   that   he  advised 
it  in  1831,  and  that  it  was  adopted  a  few  years  afterwards  by 
Neumann  and  Recamier.     In  Germany  it  has  of  late  years  been 
frequently  resorted  to,  and  Scanzoni  gives  the  following  reasons 
for  preferring  it  to  abdominal  paracentesis.     It  "  more  often  i)ro- 
duces  a  radical  cure  than  the  other  method  just  considered,  and 
that  especially  because  the  cyst,  opened   in  its  lowest  part,  can 
empty  itself  more   completely.      If  the  puncture  by  the  vagina 
were  always  possil)le,  the  abdominal  punctui-e  would  soon  entirely 
disappear  from  chirurgical  practice ;  but  unfortunately,  this  is  not 
the  case,  for  the  conditions  necessary  for  tliis  operation  arc  met 
with  in  but  few  patients ;  in  fact,  it  is  rare  that  the  lower  portion 
of  the  tumor  descends  sufficiently  low  into  the  pelvis  to  be  accessi- 
ble to  the  vaginal  touch,  and,  furthermore,  in  many  cases  where 
the  tumor  can  be  reached,  it  does  not  present  in  its  lower  jjortion 
any  cavity  filled  with  liquid,  but  only  solid  masses  of  a  sarcoma- 
tous, colloid,  or  cancerous  nature."     Kiwisch  declares  that  he  "un- 
conditionally" prefers    it   to  abdominal   tapping,  whenever   it    is 
practicable. 


'  Diet,  de  M6d.,  torn,  xxii.,  p.  589. 
45 


706  OVARIAN    CYSTS. 

By  this  method,  the  advantages  of  which  are  thus  strongly  stated 
by  the  authorities  just  mentioned,  two  of  the  dangers  of  ta})ping. 
secondary  escape  of  fluid  into  the  peritoneum,  and  consequent 
peritonitis,  are  unquestionably  avoided,  but  others  are  as  surely 
increased,  namely,  those  of  injury  to  })ortions  of  the  intestine,  and 
entrance  of  air  into  the  sac,  wnth  consequent  decomposition  of  con- 
tents, septicaemia,  and  inflammation  of  the  sac  walls.  My  experi- 
ence with  the  method  is  not  large,  but  it  leads  me  to  agree  with 
Spencer  Wells^  that,  "  as  a  rule,  air  enters  the  cyst,  the  opening 
fills  up,  and  the  fluid  remaining  in  the  cyst,  or  that  freshly 
secreted,  putrefies.  Suppurative  inflammation  of  the  lining  mem- 
brane of  the  cyst  comes  on,  and  is  accompanied  by  a  low  form  of 
exhaustive  fever  or  pyaemia."  Where  a  cyst  is  firmly  fixed  in  the 
pelvis,  however,  this  method,  followed  by  drainage  and  antiseptic 
injections,  is  one  of  great  value. 

The  operation  is  thus  performed :  the  bladder  and  rectum  having 
been  carefully  emptied,  and  the  patient  anaesthetized,  she  should 
be  placed  upon  a  table  in  the  jjosition  for  lithotomy.  The  operator 
then  introducing  the  index,  or,  as  is  better,  the  index  and  middle 
fingers  of  the  left  hand,  places  them  against  the  most  dependent 
and  accessible  part  of  the  tumor.  U[)on  the  finger  or  fingers,  a 
canula  ten  inches  long  is  i)assed  up  and  pressed  against  the  tumor, 
the  point  of  the  trocar  being  drawn  in  a  little.  The  operator  then 
plunges  the  trocar  through  the  vaginal  walls  into  the  tumor,  and 
withdrawing  it  allows  the  fluid  to  flow  away  through  the  canula. 
The  patient  is  then  i)Ut  to  bed,  quieted  by  opium,  and  guarded 
against  all  influences  which  might  induce  inflammation  as  long  as 
such  an  accident  is  probable. 

Tapping  through  the  rectum. — Should  the  surface  of  the  tumor  be 
much  more  accessible  through  the  rectum  than  the  vagina,  or  if 
for  any  other  reason,  as,  for  example,  constriction,  atresia,  or  inflam- 
mation of  the  vagina,  it  be  deemed  best  to  pierce  the  rectal  wall, 
there  is  no  objection  to  doing  so.  If  a  choice  be  admissible,  how- 
ever, no  special  reason  pointing  to  tlie  rectum  as  the  proper  point 
of  approach,  it  would  be  best  to  operate  through  the  vagina.  Fro};i 
this  canal,  fluids  escape  without  effort  on  the  part  of  the  patient . 
and  with  less  annoyance  to  her,  while  from  the  rectum  they  can  pass 
only  by  a  voluntary  act  which  exhausts  her  strength,  and  annoys 
her  by  the  necessity  of  frequent  repetition,  while  at  the  same  time 
the  gases  of  the  intestines  may  enter  the  sac  and  create  greater 


'  Diet,  de  Med.,  torn.  xxii..  p.  276. 


DRAINAGE.  707 

evil  than  the  admission  of  pure  air.  Except  as  a  resource  where 
all  other  varieties  of  paracentesis  ovarii  are  entirely  impraeticahle, 
this  method  should  be  discarded. 

Thus  far  we  have  considered  the  oi)eration  of  paracentesis  ovarii 
merely  as  a  palliative  procedure,  proving  curative  only  excep- 
tionally. The  evil  which  is  most  uniforndy  active  in  preventing 
its  curative  eft'ects,  is  rapid  reaccumulation  of  fluid  in  the  cyst. 
Indeed,  the  operation  often  seems  to  give  vigor  to  this  process,  and 
as  each  accumulation  robs  the  blood  of  some  of  its  nutritious  ele- 
ments, a  repetition  of  the  act  of  emptying  the  sac  rapidly  exhausts 
the  patient's  strength.  The  observation  of  this  fact  has  led  to  the 
adoption  of  the  method  of  which  we  come  next  to  speak. 

Drainage. — It  has  long  been  noticed  that  in  a  small  number  of 
cases  ovarian  cysts  empty  their  contents  through  the  rectum,  abdo- 
minal walls,  or  vagina,  and  continuing  to  discharge,  either  never 
refill,  or  become  obliterated.  The  following  instance  is  worthy  of 
record  as  an  example  of  how  much  benefit  may  result  from  tlds 
effort  on  the  part  of  nature  to  eft'ect  a  cure. 

Johanna  Smith,  ret.  46,  married  seventeen  years,  sterile;  came 
to  my  clinique  at  the  College  of  Physicians  and  Surgeons.  The 
patient  was  in  good  health  up  to  1859,  when  she  noticed  a  tumor 
over  the  right  ovary.  This  grew  to  an  immense  size;  so  that  for 
three  months  she  could  not  turn  in  bed  without  assistance,  and 
suffered  from  dyspepsia,  oedema  pedum,  and  other  signs  of  consti- 
tutional depreciation. 

In  June,  1861,  a  large  amount  of  sero-purulent  fluid  passed  per 
rectum,  and  this  flow  continued  for  two  months.  She  states  tliat 
after  this  time  she  left  her  bed,  a  mere  skeleton,  but  witli  no  abdo- 
minal enlargement. 

The  tumor  refilled  in  1866,  and  discharged  in  the  eame  way  in 
1868.  Since  that  time  only  a  small  tumor  has  existed,  and  the 
discharge  by  the  rectum  has  gone  on  steadily. 

She  is  now  not  very  much  emaciated,  and  suffers  from  nothing 
but  dys[)epsia  and  constipation.  She  very  frequently  feels  a  desire 
to  evacuate  the  contents  of  the  bowels,  but  only  sero-purulent 
matter  escapes. 

Vaginal  touch  shows  the  uterus  pushed  towards  the  left  nt^^tab- 
ulum  and  slightly  anteflexed.  Upon  conjoined  manipulation  a 
tumor,  the  size  of  a  cocoanut,  is  discovered  in  the  right  iliac  fossa. 
Rectal  touch  reveals,  as  high  up  as  the  index  finger  can  reach,  a 
stricture  which  prevents  fecal  matter  from  passing,  but  allows  the 


708  OVARIAN    CYSTS. 

escape  of  fluids.  Between  this  stricture  and  the  sphincter  ani  a 
large  amount  of  fluid  is  found. 

The  operation  to  which  we  apply  the  name  of  drainage  is  an 
imitation  of  this  process,  with  the  addition  of  the  injection  of 
disinfectant  and  alterative  fluids  into  the  sac. 

The  operation  consists  merely  of  vaginal  or  ahdominal  para- 
centesis, and  the  introduction  and  retention  of  a  tube  in  the  canal 
thus  created,  by  which  fluid  can  flow  out  and  injections  be  thrown 
in. 

The  proposition  of  vaginal  paracentesis,  already  mentioned  as 
claimed  by  Velpeau,  in  1831,  was  not  confined  to  evacuation  of  the 
sac,  but  comprehended  the  retention  of  a  drainage  tube,  if  such  a 
procedure  should  be  deemed  necessary.  In  more  recent  times  Ger- 
man gynecologists  have  systematized  the  operation,  and  rendered 
it  subservient  to  the  best  practical  results.  It  presents,  of  course, 
all  the  advantages  of  evacuation  of  the  contents  of  the  sac  by 
vaginal  opening,  wliile  at  the  same  time  it  obviates  the  chances  of 
failure  resulting  from  reaccumulation  and  redistention.  Statistics 
with  reference  to  it  are  not  yet  suflicicntly  complete  or  full  to 
enable  us  to  Sjieak  with  entire  confidence  of  it,  but  thus  far  its 
results  have  been  of  the  most  favorable  character  in  a  certain  kind 
of  case.  Iso  one  claims  for  it  an  extended  field  of  usefulness. 
Even  Kiwisch,  its  introducer  and  strongest  advocate,  speaks  thus 
guardedly  on  this  i)oint:  "In  our  opinion  it  is  only  of  use  in 
moderately  large,  sim})le  cysts;  because,  in  very  large  cysts,  the 
extensive  decomposition  must  be  very  exhausting  to  the  system, 
and  compound  cysts  do  not  allow  of  a  pro})er  shrivelling  of  the 
open  sac,  as  we  experienced  in  a  fatal  case,  in  wliich  two  cysts 
were  in  juxtaposition  and  only  one  could  be  punctured." 

Scanzoni  has  operated  in  this  way  fourteen  times;  eight  cases 
were  cured;  two  relapsed  in  a  few  weeks;  three  were  lost  sight  of, 
and  one  died  of  typhoid  fever  two  months  after  the  operation. 

In  America,  the  operation  lias  been  frequently  resorted  to  by 
Dr.  Emil  ISToeggerath.  His  success  has  not  been  encouraging  thus 
far,  but  he  is  favorably  impressed  in  regard  to  the  plan,  and  at- 
tributes his  unfavorable  results  to  the  fact  that  the  cases  upon 
which  he  has  operated  have  most  of  them  been  complicated  by 
malignant  or  other  serious  disease.  Dr.  Schnetter  has  had  two 
cases  which  have  proved  entirely  successful.  Dr.  Noeggerath  has 
of  late  greatly  modified,  and  I  think  improved,  the  method  of  per- 
forming this  operation. 


DRAINAGE.  709 

NoeggerailiS  o-peration  for  drainage  of  ovarian  cysts. — 1st  step.  The 
patient  lying  upon  the  back,  Sims's  speculum  is  introduced,  and 
the  anterior  vaginal  wall  and  the  base  of  the  bladder  are  held  up. 
Seizing  the  fornix  with  a  tenaculum,  the  wall  of  the  vagina,  the 
subperitoneal  areolar  tissue,  and  the  peritoneum  are  cut  through. 
2d  step.  The  cyst  is  then  felt  through  the  opening  thus  made;  a 
tenaculum  fixed  in  it,  and  paracentesis  practised  upon  the  main 
cyst  and  all  others  upon  which  it  is  practicable.  The  tumor  being 
thus  emptied,  and  the  vagina  cleansed  of  blood,  the  operator  pro- 
ceeds to  the  3d  step.  This  consists  in  turning  the  patient  upon 
the  left  side,  introducing  Sims's  speculum,  and  with  silver  wires 
stitching  the  lips  of  the  cyst  to  those  of  the  vagina.  By  this  plan 
thorough  drainage  is  secured,  the  way  is  opened  and  kejit  o])en  for 
antiseptic  injections  into  the  sac,  and  the  peritoneum  is  shut  off 
and  protected  from  contact  with  fluids.  Dr.  Noeggerath  informs 
me  that  small  endogenous  cysts,  even  without  being  opened,  shrivel 
and  almost  invariably  disappear  after  the  establishment  of  drainage. 

Kiwisi-h's  inethod. — The  operation  of  paracentesis  vaginalis  is 
performed  as  already  described.  The  fluid  of  the  cyst  having 
flowed  off,  a  director  without  a  handle  is  passed  into  the  sac 
through  the  canula,  and  held  in  position  while  the  canula  is 
removed.  A  long  probe-pointed  bistoury  is  then  passed  by  means 
of  the  director,  and  an  incision  is  made,  sufiiciently  large  to  intro- 
duce the  index  finger.  The  bistoury  and  director  are  then  witli- 
drawn,  and  a  long  flexible  tube  inserted,  which  is  allowed  to  hang 
out  of  the  vagina,  being  fastened  by  a  T  bandage  9t  the  vulva. 

After  the  operation  the  patient  should  be  kept  in  l)ed.  On  the 
second  or  third  day  symptoms  of  inflammation  generally  manifest 
themselves  by  severe  reaction,  and  for  from  ten  to  twenty  days  there 
is  often  an  ichorous  discharge  and  great  pain  in  the  surrounding 
parts.  In  favorable  cases  the  ichorous  discharge  generally  gives 
place  to  one  which  is  purulent,  and  which  disappears  in  from  five 
to  seven  weeks,  when  shrivelling  and  perfect  obliteration  are  to 
be  expected.  As  long  as  there  is  any  discharge  from  the  cyst  it 
should  be  washed  out  twice  a  day  by  an  injection  of  lukewarm 
water,  or,  what  is  better,  of  warm  water  holding  in  solution  per- 
sulphate of  iron  or  carbolic  acid.  At  the  same  time  copious  vaginal 
injections  should  be  used  to  prevent  irritation  of  the  vagina. 

The  tube  should  be  kept  in  place  until  discharge  ceases  and 
diminution  of  the  sac  has  occurred. 

Schnetter's  method.— Dr.  Schnetter,  of  this  city,  has  modified  this 
I  procedure  in  the  following  manner :   the  canula  being  introduced 


710 


OVARIAN    CYSTS. 


Fiff.  179. 


and  the  trocar  withdrawn,  a  little  knife,  one  inch  and  a  half  long 
in  the  blade,  fixed  upon  a  handle  constructed  according  to  the 
curve  and  dimensions  of  the  canula,  but  longer  than  it,  is  passed 
through  it.  As  the  handle  of  the  knife  is  longer  than  the  canula, 
this  admits  of  a  protrusion  of  the  cutting  surface  beyond  its  mouth. 
In  withdrawing  both  canula  and  knife  an  incision  is  made  by  the 
latter,  which  opens  the  way  for  the  finger  and  the  drainage-tube. 
Scanzoni,  who  has  twice  employed  Schnetter's  method,  prefers  it 
to  that  of  Iviwisch,  on  account  of  its  greater  simj)licity. 

WesCs  method. — Still   another  method  has   been    recommended 

by  Dr.  West,  of  London,  which  is  very 
simple.  The  trocar  and  canula  being 
plunged  into  the  cyst,  the  former  is 
removed  and  the  fluid  allowed  to  flow 
away.  Then  a  Ko.  12  gum-clastic  ca- 
theter is  passed  through  the  canula, 
the  canula  withdrawn,  and  the  catlie- 
ter  fixed  in  its  place  by  a  T  bandage. 
I  adopted  this  i)lan  in  a  case  which  I 
attended  with  Dr.  0.  II.  Smith,  of 
"Williamsburgh.  The  notes  in  my 
case  book  read  as  follows :  "  The  ope- 
ration of  West  was  performed  six 
weeks  ago.  The  patient  has  not  done, 
and  is  not  doing  well.  The  flow  from 
the  cyst  is  steady  and  of  rather  ofl:en- 
sive  character ;  constant  gastric  irri- 
tability has  harassed  her ;  the  pulse  is 
quick;  the  skin  dry,  and  the  mucous 
membrane  of  the  mouth  and  lips 
parched  and  cracked.  It  is  very  evi- 
dent that  the  case  will  end  fatally."^ 

The  cyst  may  be  opened  by  Scan- 
zoni's  long  trocar  and  canula,  or  by  a 
long  bistoury. 

The  most  ingenious  apparatus  which 
has  been  invented  for  the  accomplish- 
ment of  drainage  by  the  vagina  is  re- 
presented in  Fig.  179. 


Maisonneiive's  trocar  atid  per- 
manent canula.  A,  curved  trocar 
with  lancet  point,  with  camila 
pierced  at  its  extremity  by  three 
openings  ;  through  one,  after  re- 
moval of  the  trocar,  fluid  pours, 
while  through  those  on  the  sides 
the  bent  extremities  of  the  elastic 
wires  c  c  project  so  as  to  prevent 
the  escape  of  the  canula.  (Wie- 
land  and  Dubrisny  ') 


'  This  patient  subsequently  died  of  peritonitis  resulting  from  ulceration  of  the 

cyst-wall  which  penetrated  the  peritoneum.     Cystic  inflnmination  and  septicaemia 
were  evidently  set  up  soon  after  the  operation. 


INCISION.  711 

The  best  of  these  methods,  however,  appears  to  me  to  be  Noeg- 
gerath's. 

Drainage  through  the  abdominal  walls  has  been  frequently  prac- 
tised in  Germany  and  Great  Britain,  as  the  imperfect  statistical 
table  which  I  furnish  will  prove.  In  some  cases  canulse  have  been 
left  in  the  opening  made,  in  others  the  lips  of  the  cyst  have  been 
sewed  to  those  of  the  abdominal  wound,  while  in  some,  yarn  or 
tents  of  cloth  or  lint  have  been  inserted  into  the  cavity  of  the  cyst. 

Cures  by  drainage  are  of  so  much  interest  in  reference  to  the 
treatment  of  cases  too  desperate  in  their  nature  for  ovariotomy, 
such,  for  example,  as  those  accompanied  by  extensive  adhesions  to 
the  intestines,  that  I  quote  the  following  reported  by  Dr.  I*awling:' 

"Believing  that  she  must  sink  from  the  progress  of  the  disease,  I  de- 
termined to  try  an  experiment  on  her.  I  tapped  her  again,  just  below 
the  umbiheus,  and  drew  nearly  three  gallons  of  water  from  her.  I  tlien 
enlarged  the  orifice  with  a  bistoury,  making  it  sufficientlj'^  large  to  in- 
troduce my  little  finger.  I  tiien  made  a  tent,  out  of  a  soft  cotton  rag, 
about  six  inches  long,  twisted  it  so  as  to  make  it  firm,  pushed  one  end 
doAvn  to  the  bottom  of  the  sac,  leaving  about  two  inches  of  tlie  tent  ex- 
ternally, applied  a  tight  bandage  around  the  abdomen  below  the  orifice, 
also  one  above  the  orifice,  put  a  ])laster  of  basilicon  ointment  over  the 
orifice,  and  then  put  a  slack  bandage  over  the  dressing.  Evcrv  day, 
until  August  20th,  the  tent  was  removed  and  the  bandage  tio,htcned. 
Healthy-looking  pus  passed  freel}'^  from  the  orifice,  intermixcil  with  a 
little  serum.  The  tumor  gradually  diminished  in  size,  while  her  general 
health  improved  rapidly.  On  the  oOth  of  August  the  sore  was  healed 
up,  and  she  was  well." 

Incision. — In  some  cases  of  desperately  bad  character,  the  multi- 
locular  nature  of  the  sac  renders  tapping,  drainage,  and  injection 
ineiiectual  for  the  accomplishment  of  cure,  while  extensive  adhe- 
sions bind  it  to  the  abdominal  walls  so  iirmly  that  extirpation  is 
inadvisable.  Under  such  circumstances  the  operation  of  incision, 
which  consists  simply  in  laying  open  the  tumor  by  cutting  through 
the  abdominal  walls,  may  be  resorted  to. 

This  operation,  which  is  only  one  method  of  acconiiilishing 
drainage,  is  attended  by  many  dangers  and  annoyances  to  the 
])atient,  who  is  often  forced  to  submit  to  an  exhausting  and  oifeu- 
sive  discharge  for  months  after  its  performance.  It  was  fii-st  per- 
formed by  Le  Dran,  a  very  graphic  and  minute  description  of 
whose  procedure  is  given  by  Mr.  Baker  Brown.     He  performed  it 


'  Richmond  and  Louisville  Med.  Journ.,  Dec.  1870. 


712  OVARIAN    CYSTS. 

in  1836,  making  an  incision  about  four  inclies  long  through  the 
walls  of  the  abdomen  into  the  tumor,  which  he  kept  open  for  five 
months  wath  pledgets  of  lint  and  a  canula  of  sheet  lead.  Should 
it  be  found  advisable  after  abdominal  incision  to  adopt  this  method, 
if  complete  union  do  not  exist  between  the  cyst  and  abdominal 
walls,  the  lips  of  the  former  may  be  sewed  to  the  latter;  a  method 
advised  by  Mr.  Baker  Brown.  Before  making  the  abdominal 
opening,  it  has  been  advised  by  Recamier,  and  more  recently  by 
Tilt,  to  cause,  by  means  of  caustic  issues,  inflammatory  adhesions 
between  the  sac  and  abdominal  wall,  but  the  plan  has  not  met  with 
success. 

The  treatment  of  ovarian  cysts  by  incision  and  drainage  will 
never  become  popular  on  account  of  its  danger,  but  it  can  never 
pass  away,  for  the  reason  that  there  is  a  class  of  cases  the  require- 
ments of  which  can  be  met  in  no  other  way.  As  an  example  I 
instance  this :  I  made  an  abdominal  incision  to  remove  a  cyst,  and 
upon  tapping  found  its  contents  so  thick  and  contained  in  so  many 
sacs,  that  I  had  to  incise  the  main  sac  and  introduce  my  hand  to 
empty  them.  The  tumor  was  found  so  firmly  adherent  to  the  liver, 
large  intestines,  and  parts  adjacent  to  the  large  bloodvessels  on  the 
spine  that  its  removal  was  entirely  impossible.  I  therefore  evacu- 
ated all  the  cysts,  sewed  the  cyst-walls  to  tliose  of  the  abdomen, 
closed  the  abdominal  wound  in  part,  and  afterwards  used  antiseptic 
injections  and  drainage.  The  patient  died  on  the  twenty-first  day 
of  pneumonia.  Had  I  not  done  this,  what  other  resource  would 
have  been  open  to  me  by  which  to  give  the  patient  even  the  small- 
est chance  for  life  ? 

I  had  endeavored  to  present  a  statistical  table  of  the  results  of 
drainage  through  the  abdominal  walls,  but  so  difficult  have  I  found 
it  to  distinguish  between  the  reports  of  it  and  of  simple  tapping 
in  which  the  opening  has  been  left  unclosed  for  a  short  time,  that 
I  am  forced  to  ofier  it  only  as  an  imperfect  report  of  a  certain 
number  of  cases  treated  by  incision: 


INCISION. 


713 


No.  of 

Cases. 

Cured. 

Died 

2 

2 

0 

3 

0 

3 

0 

1 

1 

0 

1 

0 

I 

0 

1 

0 

1 

1 

1 

0 

I 

0 

I 

0 

1 

0 

1 

2 

1 

0 

1 

0 

1 

0 

2 

0 

1 

0 

0 

1 

0 

1 

1 

0 

0 

1 

3 

1 

2 

1 

1 

0 

Operator, 

Le  Dran,    . 

I.  B.  Brown, 

Delaporte,  . 

Velpeau,     . 

Portal, 

Boniiemain, 

Ray,  . 

Bainbridge, 

Mussey, 

Prince, 

Djondi, 

Galenuowsky, 

Buhring,     . 

Pagenstecher, 

Ollenroth,  . 

Douglass,    . 

Clay,  .         , 

Farrell, 

Hutchinson, 

Paget, 

Trowbridge, 

Weber, 

Thomas, 

Pawling,     . 

33  21  12 

In  some  of  these  cases  the  entire  sac  was  filled  with  pledgets  ot 
lint  saturated  with  caustic  solutions;  in  some,  threads  of  worsted 
or  other  suhstances  were  rolled  into  balls,  dropped  into  the  sac, 
and  the  ends  allowed  to  hang  out  of  the  incision ;  in  some,  tents 
were  introduced,  while  in  others,  drainage-tubes  were  employed. 
The  time  during  which  the  escape  of  fluid  continued,  varied  very 
much.  Sometimes  it  ceased  in  a  few  weeks,  while  in  other  cases 
it  continued  for  a  period  varying  from  eight  to  tAvolve  months. 

Although  from  the  presentation  of  facts  just  made  it  is  evident 
that  the  operation  of  incision  is  one  attended  by  great  daiii^cei-s,  it 
must  not  be  forgotten  that  in  a  certain  class  of  cases  it  may  render 
valuable  service.  When,  for  example,  the  tumor  is  multilocular 
and  firmly  adherent,  it  may  be  resorted  to  with  two  good  results: 
first,  it  enables  the  operator  more  perfectly  than  any  other  method 
to  reach  successive  cysts;  and  second,  it  ofters  a  chance  of  iiirma- 
nent  cure,  without  removal  of  the  sac,  almost  equal  in  jiroj^ortion 
to  two  out  of  three.  The  emptying  of  one  large  cyst  will  bo  hotter 
accomplished  by  simple  drainage,  but  in  case  a  number  of  cysts 
exist,  that  plan  may  fail. 


714  OVARIAN    CYSTS. 

Ivjection  into  the  Sac. — The  insufficiency  of  simple  tapping  of 
ovarian  sacs  led  Denman,'  Bell,  Hamilton,  and  others,  to  inject 
into  them  solutions  of  sulphate  of  zinc  and  other  substances,  but 
without  good  effect.  In  1846,-  Dr.  Alison,  of  Indiana,  U.  S.,  essayed 
the  injection  of  tincture  of  iodine  with  a  successful  issue,  after 
repeated  trials  on  the  same  patient.  Although  others  in  Franco 
and  Germany  employed  the  method  after  this  time,  it  was  not 
systematized  and  placed  upon  the  footing  of  a  recognized  procedure 
until  it  received  the  attention  of  M.  Boinet,  of  Lyons.  This  prac- 
titioner, bringing  a  great  deal  of  enthusiasm  to  the  work,  soon 
accumulated  a  large  experience.  Among  gynecologists  of  our  day 
the  sphere  of  the  operation  has  become  very  much  limited,  though 
it  is  still  applied  to  monocysts  of  moderate  size,  the  contents  of 
which  are  not  very  viscid  or  are  charged  with  blood  or  pus.  "  If 
the  jEluid,"  says  Feaslee,^  "  is  very  dense  and  highly  albuminous, 
oily,  or  gelatinous,  the  operation  will  not  succeed."  Wells^  declares 
that,  "when  iodine  injection  is  really  useful,  and,  in  my  opinion, 
the  only  class  of  cases  where  its  employment  should  be  recom- 
mended, is  in  cases  where,  after  tapping,  either  by  the  abdominal 
wall,  vagina,  or  rectum,  cyst  inflammation  has  occurred  and  the 
patient  is  sufl'ering  from  absorption  of  the  decomposing  contents  of 
the  cyst."  Even  here  he  advocates  it  merely  as  an  adjuvant  to 
drainage.  "At  present,"  says  Courty,  "the  profession  shows  a 
strong  tendency  to  abandon  this  treatment,  the  dangers  of  which 
are  often  manifested  by  fatal  results." 

The  injection  of  iodine  is  not  very  painful,  ordinarily  producing 
merely  a  burning  sensation,  and,  when  it  is  practised  in  appro[)riate 
cases,  yields  a  good  proportion  of  success.  Sometimes,  as,  for 
example,  in  a  case  published  in  the  Sydenham  Society's  Year-book 
for  1861,  b}--  Lowenhardt,  the  pain  resulting  from  this  procedure 
is  excessive,  and  the  shock  to  the  nervous  system  so  great  as  to 
destroy  life.  Boinet  declares  that  so  long  as  the  injected  fluid  is 
conflned  to  the  sac,  pain  and  tendency  to  collapse  do  not  occur, 
they  being  due  to  its  entrance  into  the  peritoneum.  This  view  is 
sustained  by  Lowenhardt 's  case,  in  which  a  post-mortem  examina- 
tion was  made,  and  revealed  a  "  small  amount"  of  iodine  in  the 
peritoneum.  The  reporter  lays  no  stress  upon  this,  and  yet  the 
symptoms  of  which  the  patient  died  were  just  those  witnessed 
after  passage  of  fluids  through  the  Fallopian  tubes. 

'  Simpson,  op.  cit.,  p.  362.  *  Peaslee,  Ovar.  Tumors,  p.  11. 

3  Op.  cit.,  p.  207.  4  Op.  cit.,  p.  287. 


INJECTION    INTO    THE    SAC. 


715 


The  view  formerly  entertained  that  the  curative  effect  of  the 
injection  of  iodine  depends  upon  the  establishment  of  adhesive 
inflammation  in  the  cyst  walls  is  now  abandoned.  It  is  regarded 
as  producing  an  altered  state  of  the  walls,  and  thus  checking  exces- 
sive secretion  of  fluid. 

Of  the  first  hundred  cases  of  cystic  disease  of  the  ovary  treated 
in  this  method  by  Boinet,  sixty-two  were  cured,  sixteen  died,  and 
twenty-two  were  improved.  Subsequently,  after  selecting  his  cases 
with  more  caution,  he  obtained  a  success  of  ninety  per  cent. 
Twenty-seven  out  of  his  last  twenty-nine  cases  were  successful. 
Courty  reviews  these  statistics  in  the  following  words:  "  According 
to  this  honorable  practitioner,  they,  the  injections,  produced  a  cure 
in  three  out  of  five  cases,  and  always  a  remarkable  improvement. 
It  is  to  be  regretted  that  these  fortunate  results  have  not  been  re- 
produced in  such  satisfactory  proportions  in  the  experience  of  the 
majority  of  physicians  who  have  had  i^ecourse  to  the  same  method." 
It  is  difiicult,  however,  to  regard  this  criticism  as  just,  when  we 
see  so  reliable  an  authority  as  Velpeau  reporting,  as  he  did  in  a 
discussion  in  the  Academy  of  Medicine,  one  hundred  and  thirty 
cases,  not  operated  upon  by  himself,  as  yielding  sixty-four  cures 
and  thirty  deaths.  Even  the  statistics  of  Dr.  West,  whose  extreme 
accuracy  as  an  observer  is  well  known,  prove  the  fact  tljat  the 
operation  of  injection  of  iodine  is  not  as  dangerous  as  M.  Courty 
appears  to  imagine.    The  results  of  other  operators  are  here  given : 


Author. 

Cazeaux  .     .  . 

Gunther  .     .  . 

Simpson   .     .  . 

Scanzoni  .     .  . 
West    .... 

Tyler  Smith  .  . 

Peaslee     .     .  . 


No.  of  cases. 

Cures. 

Failures. 

Deaths. 

Doubtful. 

62 

48 

11 

3 

l!i8 

32 

61 

59 

40  or  50  (?) 

— 

— 

1 

4 



— 

4 

10 

3 

6 

1 

12 

2 

9 

1 

6 

1 

3 

1 

1 

Wells  has  employed  the  method  8  times.  In  six,  no  more  good 
was  done  than  tapping  would  have  accomplished  ;  and  in  two,  the 
contents  ot  which  had  been  limpid,  refilling  did  not  occur  lor  two 
years.     In  such  cases  as  these  last,  tapping  often  proves  curative. 

Boinet  employs  for  injection  always  the  same  amount  of  fluid 
whatever  be  the  capacity  of  the  cyst,  for  all  that  he  considers 
necessary  is  the  contact  of  the  alterative  fluid  with  the  entire  area 
of  diseased  surface.     He  injects  about  six  ounces  of  the  following 


716  OVARIAN    CYSTS. 

mixture,  brings  it  in  contact  with  the  entire  surface  of  the  sac  by 
gentle  agitation  and  then  withdraws  it. 

R. — Aquce  destillat.  ^xxv. 

Tr.  iodini  (Codex),  gxxv. 
Potassii  iodidi,  3j. 
Acidi  tannici,  3ss. — M. 

By  others  the  pure  tincture  of  iodine  has  been  employed. 

Should  a  great  deal  of  tlie  drug  be  left  in  the  sac,  disagreeable, 
but  not  dangerous  symptoms,  sometimes  follow.  Neither  iodism 
nor  any  destructive  inflammation  of  the  sac  walls  has  ever  oc- 
curred even  from  leaving  the  whole  quantity  injected.  That  certain 
evils  result  from  doing  this,  and  from  the  escape  of  tlie  surplus 
into  the  peritoneum,  there  can  be  no  doubt,  while  the  advantages 
likely  to  accrue  from  the  practice  are  not  apparent. 

Boinet's  method  of  iniectino;  the  fluid  is  this:  a  trocar  and 
canula  being  passed,  the  fluid  is  removed  from  the  cyst.  A  flexible 
catheter  is  then  passed  through  the  canula,  deep  into  the  cyst,  and 
by  means  of  a  hard  rubber  syringe  the  fluid  is  injected  through 
this.  After  having  been  retained  for  ten  or  fifteen  minutes  it  is 
allowed  to  escape,  or  may  be  drawn  off  by  the  Byringe.  By  Boinet 
the  catheter  is  kept  in  position  for  some  days  or  weeks,  and  througli 
it  a  solution  twice  as  strong  in  iodine  is  soon  used.  Then  as  the 
cyst  lessens  considerably,  pure  tincture  is  employed.  All  other 
operators  remove  the  catheter  immediately,  close  the  wound  care- 
fully by  adhesive  plaster,  apply  a  compress  and  bandage,  and  keep 
the  patient  strictly  confined  to  one  position. 

It  appears  to  me  that  the  leaving  of  the  catheter  for  subsequent 
injections  should  be  restricted  to  vaginal  tapping,  followed  by 
drainage. 

I  have  recently,  in  several  cases,  emptied  an  ovarian  sac  by  the 
aspirator,  and  without  withdrawing  the  needle,  filled  it  with  tinc- 
ture of  iodine,  and  in  ten  minutes  again  drawn  it  off.  It  is  a  most 
simple,  safe,  and  effectual  method  of  practising  this  procedure,  and 
must  supersede  that  just  mentioned,  for  it  jiossesses  all  its  advan- 
tages, while  it  is  free  from  most  of  its  dangers. 

Even  years  after  obliteration  of  the  injected  sac  a  return  of  the 
disease  may  take  place.  This  probably  arises  from  the  development 
of  a  minute  cyst  whose  growth  was  retarded  by  the  alterative  in- 
fluence of  the  remedy,  but  whose  vitality  was  not  wholly  destroyed. 

Resume. — We  have  now  considered  the  following  surgical  means 
for  the  cure  of  fluid  ovarian  tumors: 


OVARIOTOMY.  717 

Tapping ; 
Drainage ; 
Incision ; 
Injection. 

In  leaving  the  subject  let  me  endeavor  to  point  out  those  condi- 
tions which  are  especially  appropriate  for  each : 

1st.  Tapping  as  a  palliative  measure  may  be  practised  upon  any 
form  of  cystic  ovarian  tumor ;  as  a  curative  means  it  should  be 
relied  upon  only  in  cysts  of  the  broad  ligament  and  other  pelvic 
cysts  closely  resembling  ovarian  cystoma  clinically,  but  differing 
greatly  from  it  histologically. 

2d.  Drainage  finds  its  appropriate  and  important  field  in  cysts 
which  are  bound  down  in  the  pelvis,  are  readily  attainable  through 
the  vagina,  or  have  formed  attachments  to  the  abdominal  viscera, 
and  are  not  susceptible  of  removal  by  ovariotomy.  It  may  like- 
wise be  attempted  in  small  oligocysts,  in  the  hope  of  avoiding 
ovariotomy  at  a  later  period. 

3d.  Incision  is  a  last  resort  which  enables  the  operator  to  freely 
break  up  the  cysts  of  a  multilocular  tumor  which  is  so  intimately 
connected  with  important  viscera  of  the  abdomen  as  to  render  its 
removal  utterly  impossible. 

4t]i.  Injection  of  iodine,  which  may  with  great  advantage  be 
combined  with  drainage,  should  be  employed  alone  only  in  the 
hope  of  avoiding  ovariotomy  at  a  later  period,  in  cysts  of  moderate 
size,  with  few  compartments,  and  containing  a  fluid  which  is  not 
very  viscid  and  dense. 


CHAPTER    XLVI. 

OVARIOTOMY. 

Definition. — Ovariotomy,  or,  as  Peaslee  with  greater  regard  for 
philology  proposes  to  term  it,  Oophorectomy,  consists  in  tlie  extir- 
pation of  the  diseased  ovaries. 

History. — The  history  of  the  operation  goes  back  only  to  a  very 
recent  date.  It  has  become  customary  for  those  who  have  written 
upon  it  to  cite  ancient  authors  to  prove  that  even  as  long  ago  as 


718  OVAKIOTOMY. 

the  time  of  the  early  Greeks  the  ovaries  were  often  removed  in  the 
inferior  animals  as  is  done  in  our  own  time.  The  writings  of 
Aristotle  put  this  beyond  question.  It  is  even  asserted  that  among 
the  Lydians  castration  of  the  human  female  was  practised  in  order 
to  enable  them  to  serve  as  eunuchs.  In  more  recent  periods,  we 
are  told  by  "VYierus,  that  a  Hungarian  swineherd,  incensed  by  the 
lasciviousness  of  his  daughter,  removed  her  ovaries,  in  hope  of 
reformation,  after  the  manner  in  which  he  was  in  the  habit  of 
spaying  Ins  swine.  Towards  the  close  of  the  eighteenth  century 
both  ovaries,  which  had  descended  into  the  inguinal  canals,  were 
removed  by  Dr.  Percival  Pott,  of  England.  But  all  this,  though 
interesting  as  a  matter  of  physiology,  has  little  to  do  with  the 
operation  of  ovariotomy,  according  to  the  true  signification  of  the 
term.  In  the  one  case  a  minute  and  healthy  gland,  which  is 
sparsely  supplied  with  blood,  was  removed  from  a  healthy  perito- 
neal cavity.  In  the  other  a  huge  sac,  which  is  supplied  by  large 
bloodvessels,  and  has  in  many  instances  contracted  adhesions  to  a 
diseased  peritoneum,  requires  extirpation. 

The  idea  of  removing  large  ovarian  cysts,  even,  is  not  new,  since 
it  was  discussed  in  1685  by  Schorkopff,  in  1722  by  Schlenker,  in 
1731  by  "VVillius,  in  1751  by  Peyer,  and  in  1752  by  Targioni.  In 
1758,  Delaporte  even  went  so  far  as  formally  to  propose  the  opera- 
tion to  the  Royal  Academy  of  Surgery.  As  the  eighteenth  century 
approached  its  close,  the  suggestions  of  the  writers  already  men- 
tioned were  not  forgotten,  but  were  from  time  to  time  repeated  ; 
among  others  by  John  Hunter  in  1787,  and  later  still  by  William 
Hunter.  In  1798,  Chambon  ventured  to  prophesy  that  it  would  in 
time  become  a  recognized  resource  in  surgery,  and  in  1808^  Samuel 
d'Escher,  a  student  of  Montpellier,  proposed  a  specific  plan  for  its 
performance  based  upon  the  teachings  of  one  of  his  masters,  M. 
Thumin. 

In  1786,  one  observer  stood  ujicn  the  very  verge  of  the  great 
discovery,  very  much  nearer  than  Laumonier,  by  some  supposed  to 
be  the  discoverer,  ever  did,  and  yet  failed  to  systematize  it  as  a 
surgical  resource.  Like  many  a  man  before  and  since  his  time,  he 
recognized  and  appreciated  a./aci,  but  failed  to  connect  this  with  a 
law.  The  following  is  a  quotation  frc^m  a  work  written  by  Thomas 
Kirkland,  an  Englishman,  and  published  in  London  in  1786.  It  is 
entitled,  "An  Inquiry  into  the  Present  State  of  Medical  Surgery."'' 


•  Wieland  and  Dubrisay,  French  translation  of  Churchill  on  Dis.  of  Women. 

*  Med.  Record,  June  15th,  1867,  from  Exchange. 


HISTORY.  719 

"  A  woman,  betwixt  twenty  and  thirty  years  of  age,  had  been  tapped 
twice  fur  an  ascites,  and  a  large  quantity  of  water  taken  away  at  each 
time ;  but  after  the  last  operation  the  puncture  did  not  heal,  and  in  a 
little  time,  a  substance  thej^  did  not  understand  protruding,  I  was  desired 
to  see  her.  It  was  evidently  a  part  of  a  cyst,  and,  as  it  had  alreadj' 
dilated  the  sore,  I  persuaded  her  to  let  it  alone  till  the  opening  became 
larger,  in  hope  of  a  better  opportunity  of  affording  relief,  Accordinffly, 
in  ten  days  or  a  fortnight  the  protrusion  was  much  larger,  and  by  the 
help  of  a  dry  cloth  a  cyst  that  would  contain  five  or  six  gallons  of  water 
was  gradually  extracted.  More  than  a  quart  of  matter  immediately 
followed,  and  more  was  daily  discharged  for  some  time,  yet  the  woman 
recovered  without  further  trouble  than  keeping  the  parts  clean,  and  after- 
wards bore  several  children." 

Later  on  in  his  v\^ork  lie  says: 

"We  have  given  an  instance,  p.  195,  where  a  cyst  being  taken  away 
cured  an  ascites;  and  seeing  medicines  do  not  avail  in  encysted  dropsies 
of  the  abdomen,  is  it  not  worth  our  while  to  consider  whether,  when  they 
are  unconnected  with  the  adjacent  parts,  after  taking  away  the  water,  the 
patient  might  not  sometimes  be  cured  by  enlarging  the  puncture,  press- 
ing the  cyst  forward,  and  draining  it  out?" 

He  then  proceeds  to  examine  the  difficulties  in  the  way  and  the 
objections  which  may  be  hronght  against  the  operation,  and  thus 
concludes: 

"At  present,  T  offer  these  hints  to  those  who  think  tlie  subject  deserv- 
ing attention,  and  time  will  probably  determine  the  question." 

Thus,  as  we  advance  from  more  remote  periods  to  the  beginning 
of  the  nineteenth  century,  we  find  the  minds  of  physicians  being 
gradually  prepared  for  the  reception  of  ovariotomy,  as  its  consum- 
mation was  step  by  step  approached.  But  all  that  we  find  accom- 
plished up  to  this  time  is  the  promulgation  of  ideas,  prophecies, 
and  propositions,  and  the  licrforraance  of  accidental  operations,  or 
of  those  upon  healthy  ovaries. 

In  1809,  the  first  real  c::se  of  ovariotomy  ever  undertaken  was 
successfully  performed  l)y  Dr.  K}ihraim  McDowell,  of  Kentucky. 
His  lirst  case  was  successful,  the  patient  living  twenty-fiv(>  years 
afterwards.  Subsequently  he  oi-)erated  thirteen  times,  with  eight 
favorable  results.  It  may  confidently  be  asserted  that  the  history 
of  no  operation  has  been  more  thoroughly  sifted  than  this,  and  that 
up  to  the  present  time,  nothing  can  be  clearer  than  the  fact  that  to 
McDowell  belongs  the  credit  of  priority  of  performance.     It   is 


720  OYAKIOTOMY. 

interesting  to  examine  the  competitive  claims  wliicli  have  been 
put  fonvard  in  reference  to  the  matter.  First,  in  chronological 
order,  is  that  of  Dr.  Houstoun,'  of  Scotland,  who  operated  in  1701, 
and  whose  case,  says  Mr.  Wells,^  makes  it  "  appear  that  ovariotomy 
originated  with  British  surgery,  on  British  ground."  This  state- 
ment will  excite  wonder,  and  the  claims  of  the  operator  fail  to  at- 
tract attention,  when  it  is  stated  that  nowhere  does  Houstoun  claim 
to  have  removed  the  cyst  or  even  a  part  of  it.  He  merely  treated 
a  case  of  ovarian  cyst  successfully  by  incision. 

The  second  is  that  of  Laumonier,  of  France.  Of  him  Baker 
Brown  says:  "The  first  who  attempted  extirpation  appears  to  have 
been  Aumonier,  of  Rouen,  in  1782,  and  he  was  successful."  In  this 
statement,  as  Di-.  l*arvin  has  pointed  out,  Mr.  Brown  was  wrong  in 
three  points:  first,  as  to  tlie  fact;  second,  as  to  the  name  of  the 
operator;  and  third,  as  to  the  date.  The  supposed  ovariotomy  was 
performed  in  1776,  by  Laumonier,  and  was  really  the  opening  of  a 
pelvic  abscess. 

The  third  is  that  of  Dzondi,  of  Ilalle.  As  the  patient  was  a  boy, 
the  claim  requires  no  further  consideration. 

In  1821,  Dr.  Nathan  Smith,  of  tliis  country,  operated  success- 
fully. In  1823,  Dr.  Lizars  endeavored  to  introduce  the  ojieration 
into  Scotland,  and  operated  four  times,  but  his  results  were  bad. 
In  one  case  the  tumor  was  uterine  and  was  not  removed,  in  one  no 
tumor  could  be  discovered  after  abdominal  section,  and  one  of  the 
two  cases  upon  which  ovariotomy  was  i)erformed  died. 

Since  this  period,  Atlee,  Peaslee,  Kimball,  and  Dunlap  have 
been  most  influential  in  establishing  the  operation  in  America. 
In  England,  Dr.  Charles  Clay,  in  1840,  pressed  it  upon  the  notice 
of  the  profession,  and  he  was  soon  ably  sustained  by  Lane,  Wells, 
Keith,  Bryant,  Baker  Brown,  and  many  others,  whose  names  have 
become  famous  in  connection  with  it. 

"  It  is  only  within  the  last  five  years,"  says  Grenser,  "that  much 
progress  has  been  made  in  Germany  in  this  operation."  Unfor- 
tunately for  many  years  insuccess  ap}>eared  to  attend  it,  and  thus 
the  voices  of  the  most  eminent  and  authoritative  were  raised  , 
against  it.  Of  the  first  three  patients  ever  operated  upon  there,  { 
(by  Chrysmar,  in  Wurtemberg,)  two  died.  Chrysmar  commenced 
operating  in  1819,  and  his  results  were  certainly  not  such  as  to 
popularize  a  new  and  dangerous  procedure.  In  1828,  the  adverse 
criticism  of  the  great  Dieifenbach  was  pronounced  in  these  strong: 


'  Amer.  Jonrn.  of  Med.  Sciences,  vol.  vii,  1849,  p.  534.  *  Op.  cit.,  p.  299. 


HISTORY.  721 

terms:  "  ^Whoever  considers  the  opening  of  the  abdominal  cavity  as 
a  liglit  matter,  and,  .as  Lizars  seems  to  believe,  that  the  difficulties 
are  small,  whoever  thinks  that  this  operation  is  accompanied  by 
no  more  dangers  than  other  operations,  must  be  very  thoughtless  • 
for  me,  my  one  case  is  sufficient."  The  "one  case"  to  which  he 
refers,  and  from  wdiich  he  drew  so  illogical  and  hasty  a  conclusion, 
was  an  incomplete  operation.  In  spite  of  the  adverse  weight  of 
this  opinion  in  1835,  Quittenbaum,  in  1841,  Stilling,  and  in  1851, 
Martin,  operated  in  a  few  cases,  and  with  varying  success.  Writing 
of  the  operation  at  this  time,  when  overclouded  by  repeated  in- 
successes  it  had  failed  to  command  the  confidence  of  the  profession, 
Grenser  says :  "  Most  of  the  ovariotomies  performed  within  the  last 
forty  years  had  a  fVital  termination,  and  as  a  consequence  reliance 
could  not  be  felt  in  it,  and  confidence  in  it  was  altogether  shattered 
when  the  celebrated  Dieffenbach  took  ground  against  the  operation." 
Diefienbaeh's  opinion,  in  1828,  has  been  given  ;  let  us  see  how  the 
experience  of  twenty  years  affected  it.  In  1848,  he  wrote :  "  The 
operation  does  not  benefit  either  patient  or  physician ;  the  idea  of 
opening  into  the  abdomen  of  a  sick,  cachectic  woman,  affected  with 
a  hard  tumor  of  the  ovary,  or  even  employing  Lizar's  method  with 
cross-incisions,  in  order  to  remove  the  tumor  by  force,  seems  neither 
reasonable  nor  useful."     He  modified  his  opinion  somewhat  wheye 

■•  the  tumor  was  fluid,  of  small  size,  and  movable.  Thus  wrote  the 
great  surgical  light  of  Germany,  and  while  he  wrote  American  and 

i  English  surgeons  were  gaining  great  results  for  humanity  and  for 

•  science  in  this  same  field.     It  must  not  be  supposed  that  even  in 
his  own  country  advances  were  not  being  made,  for  Stilling,  Bliring, 
and  others  were  carrying  on  the  work.     In  1850,  the  latter  an- 
nounced an  important  advance,  namely,  that  adhesions  should  not 
'  be  considered  as  a  contraindication  to  removal. 

In  1852,  Edward  ]\Iartin   declared   that  the  question  was  no 

I  longer  as  to  the  propriety  and  efllciency  of  ovariotomy,  but  of 
circumstances  favorable  to  success,  ^Martin's  rules  for  operating, 
read  even  by  our  present  lights,  are  most  of  them  excellent. 

Al)out  this  time  the  voice  of  Kiwisch  was  raised  against  the 
[operation.  Ile^  collected  the  statistics  of  54  cases,  of  which  51 
3nded  fatally,  and  concluded  that  certainly  over  half  of  all  sub- 
mitted to  operation  died.  It  was  soon  after  this  that  Scanzoni 
Und  Gustav  Simon  gave  their  evidence  against  the  operation,  and 
Increased  its  disfavor  to  such  a  degree  that,  as  Grenser  says,  "  its 

'  Grenser,  Report  on  Ovariotomy  in  ficrniany.  ^  Grenser.  loc.  cit. 

46 


722  OVARIOTOMY. 

very  existence  was  threatened."  This  opposition  seems  to  have 
lasted  up  to  1864,  when  the  tide  appeared  to  turn  in  its  favor,  and 
now  it  numbers  among  its  advocates  Breshxu,  Gusserow,  llilde- 
l)randt,  Spiegelberg,  Martin,  Stilling,  Veit,  Wagner,  and  Billroth. 
Grenser  collects  in  1871  the  statistics  of  129  o})crati()ns  performed 
in  Germany,  of  which  60,  a  little  less  than  half,  recovered.  When 
these  results  are  compared  with  English  and  American  statistics, 
they  show  that  Germany  lias  much  to  make  up ;  hut  experience 
has  taught  us  how  surely  and  quickly  she  will  stand  abreast  of 
other  nations  in  this  as  she  docs  in  every  other  advance  and  im- 
provement. The  report  of  Grenser  u[)on  ovariotomy  in  Germany, 
and  another  u})on  the  operation  in  England,  will  undoubtedly  do 
a  great  deal  towards  the  accomplishment  of  this  result. 

According  to  Grenser  we  owe  to  Germany  two  of  the  most  im- 
portant of  the  improvements  which  have  taken  place  in  the  opera- 
tion since  the  days  of  McDowell:  first,  the  adoption  of  the  short 
incision  and  tapping  the  sac  in  sitii^  which  originated  with  Quit- 
tenbaum ;  second,  the  external  treatment  of  the  pedicle,  which  he 
declares  was  first  resorted  to  and  its  advantages  insisted  ujioii  by 
Stilling  in  1841,  and  not  by  Duffin  in  1850.  In  1849,  Martin  first 
secured  the  pedicle  in  the  lips  of  the  wound.  There  are  other 
advances  which  have  been  made  in  Germany  ;  but  I  mention  only 
those  which  have  had  a  decided  influence  on  the  operation. 

Into  France  the  operation  was  introduced,  or  as  some  French' 
writers  express  it,  "  reintroduced,"  by  Dr.  Woyerkowski,  in  1844. 
It  was  subsequently  performed  by  Vaullegeard,  in  1847,  and  later 
still  by  N^laton,  Maisonneuve,  Jobert,  Demarquay,  and  other 
surgeons  of  Paris.  The  results  of  these  attempts,  however,  had 
the  efix'ct  of  casting  discredit  on  the  operation,  from  which  it  is 
only  now  emerging,  thanks  to  the  writings  of  Jules  Worms, 
Oilier,  Labalbary,  Vegas,  and  more  especially  to  those  of  Koeberlu, 
of  Strasbourg.  When  it  is  stated  that  all  tliese  writers  have  pub- 
lished since  1862,  it  will  be  appreciated  how  recent  is  the  fiivorable 
reception  of  the  operation  in  France. 

M.  Boinet,  in  1867,  reid  an  essay^  before  the  Academy  of  Medi- 
cine, strongly  advocating  it,  and  "reprobating  the  timidity  of 
French  surgeons  who  have  so  long  recoiled  before  it." 

Up  to  July,  1868,  Penn,  of  Paris,  had  had  seven  recoveries  out 
of  ten  cases,  and   in  1870  and  '71,  out  of  thirty-two  operations, 

'  Wieland  and  Dnbrisiy.  tho  Frpiich  translators  of  Churchill. 
2  N.  Y.  ]\[ed.  Reconl,  Julv,  18GT. 


VARIETIES.  723 

twenty-six  recoveries  took  place.  In  1873,  he  wrote  a  work  upon 
Hysterotomy  for  Fibroids  and  Fibro-Cysts,  in  which  he  claims 
seven  recoveries  for  nine  operations.  Nothing  could  more  surely 
mark  the  advance  of  the  operation,  as  well  as  the  rapidly  increasing 
1  loldness  and  skill  of  French  surgeons,  than  this  announcement. 

Ovariotomy  has  now  been  performed,  and,  in  most  instances, 
repeatedly  performed  in  almost  every  civilized  country  of  the 
earth.  In  Sweden,  Skoldberg  has  performed  it  twenty-one  times, 
Avith  seventeen  recoveries. 

In  concluding  the  history  of  ovariotomy,  it  may  be  said  that  the 
conception  of  the  operation  in  all  its  steps  is  over  a  hundred  years 
old,  and  is  of  European  origin;  that  for  its  accomplishment  we 
are  indebted  to  what  M.  Piorry  once  styled,  "  une  audace  Amdri- 
caine,"  which  was  supplied  by  Dr.  McDowell ;  and  that  many  of 
the  important  improvements  which  have  since  been  introduced, 
we  owe  to  Great  Britain.  Pre-eminently  an  Anglo-American  pro- 
cedure, it  has  only  within  the  last  decade  assumed  its  legitimate 
place  in  Germany  and  France,  but  in  both  countries  it  is  not  merely 
maintaining  itself,  but  being  improved  and  advanced  towards  per- 
fection. 

Varieties. — There  are  two  forms  of  the  operation;  one,  abdominal 
ivariotomy,  in  which  the  cyst  is  removed  through  the  incised 
ihdominal  walls ;  the  other,  vaginal  ovariotomy,  in  which  a  small 
yst  is  removed  by  incision  through  the  fornix  vaginfB.  Incom- 
plete cases,  or  those  in  which  only  a  portion  of  the  sac  is  removed, 
lave  also  been  grouped  under  the  first  head,  but  very  improperly 
o,  for  less  than  complete  removal  constitutes  an  entirely  ditFerent 
operation,  which  is  known  as  partial  excision. 

It  has  already  been  stated  that  extirpation  of  the  ovaries  not 
Itered  by  disease  was  probably  performed  in  very  ancient  times, 
'his  was  done,  if  we  may  rel_y  upon  the  vague  allusions  which 
ome  down  to  us  upon  the  subject,  for  other  than  scientific  pur- 
oses.  Extirpation  of  the  ovaries  for  the  immediate  accomplishment 
f  the  menopause,  and  the  cure  of  certain  very  grave  nervous  phe- 
omena  and  incurable  disorders,  which  are  excited  by  ovulation 
id  menstruation,  has  recently  been  advocated  and  practised  b}' 
'r.  Robert  Battey,'  of  Georgia,  U.  S.  The  circumstances  under 
;  hich  he  proposes  to  resort  to  the  procedure  are  here  given  in  his 
vn  words : 


»  Essay  before  Ga.  Med.  Association,  April,  1873. 


724  OVAEIOTOMY. 

"What  I  do  propose  is  this:  Ovariotomy  to  determine  the  change  of 
life ;  and  the  change  of  life  for  any  grave  disease  ivhich  is  incurable 
without  it,  and  which  is  curable  with  it.  *  *  *  * 

I  have  proposed  for  j^our  acceptation  a  new  operation  in  surgery,  which 
I  believe  to  be  original  with  myself  in  its  concejjtion,  original  in  its  elabo- 
ration, and  original  in  its  snccessful  execution.  I  have  related  to  you  the 
history  of  the  case  up  to  the  present  time.  I  have  endeavored  to  show 
you  that  the  change  of  life  was  a  reasonable  remedy  for  the  morbid  con- 
ditions present  in  the  case ;  that  it  was  reasonable  to  expect  that  the 
removal  of  the  ovaries  would  determine  the  change  of  life.  I  have  asked 
3'^ou  to  hold  fast  to  your  faith  in  the  ovidar  theory  of  menstruation,  not- 
withstanding some  anomalous  results  of  double  ovariotomy." 

Like  every  other  bold  innovation  in  medicine,  this  will  have  to 
run  the  gauntlet  of  prejudice,  and  stand  the  test  of  experience.  It 
is  too  young  as  yet  to  be  decided  upon,  and  is  unquestionably  a 
procedure  which  may  be  greatly  abused.  !N^evertheless,  I  freely 
commit  myself  to  the  opinion  that  it  has  a  future  before  it  which 
will  be  rich  in  good  results.  Since  the  ]  ublication  of  Dr.  Battey's 
essay,  I  have  met  in  the  Woman's  Hospital  with  one  case  which  I 
felt  demanded  a  resort  to  it,  and,  with  the  full  endorsement  of  my 
colleagues  Sims,  Peaslee,  Metcalfe,  and  Fordyce  Barker,  it  was 
safely  performed.  Three  months  have  since  elapsed,  a  period  too 
short  to  warrant  a  report  of  the  ease,  but  I  may  here  say  that  the 
patient's  condition  has  been  greatly  improved. 

Advantages  of  Ovariotomy. — The  advantages  of  the  operation  are 
these:  it  enables  us  to  remove  solid  and  polycystic  tumors,  Avhich 
are  curable  by  no  other  method,  atid  to  extirpate  those  of  unilocular 
form,  which  have  resisted  all  other  procedures.  Great  as  are  the 
dangers  of  the  operation,  it  often  otters  a  better  prospect  for  ' 
recovery  than  any  of  the  other  plans  mentioned  in  connection  with 
the  treatment  of  these  tumors,  and  in  case  of  their  failure  it  always 
remains  as  a  reasonable  ho[)e  for  the  patient,  whose  life  will  proba- 
bly terminate  in  three  or  four  years  if  art  do  not  interfere. 

Dangers. — The  dangers  which  attend  it  are  numerous  and  grave.  ■ 
The  followins:  table,  constructed   by  Dr.   Peaslee   upon  the  post- 
mortem evidence  of  50  cases,  will  exhibit  them  at  a  glance. 

Peritonitis,     .         .         .         .12  Strangulation  of  intestine  in 

Sopticaemia 9  wound 1 

Shock  or  collapse,           .         .       7  Diarrhoea,            .         .         .1 

Exhaustion,   ....       7  Erysipelas,           .         .         .1 

Shock  and  septicaemia,  .         .       1  Tetanus,      ...         .1 

Hemorrhage,          ...       9  Ulceration  through  bladder,     1 

Unknown,    ....     9 


DANGERS.  725 

It  will  be  seen  from  this  table  that  peritonitis  destroyed  one- 
;iuarter  of  all  who  died  from  the  operation,  and  septicaemia,  or 
absori)tion  of  putrid  material,  one-sixth.  After  these  causes  fol- 
lowed those  directly  resulting  from  the  depressing  influence  of  the 
operation  upon  the  nervous  system. 

Dr.  John  Clay  makes  the  following  analysis  of  the  causes  of 
death  in  150  fatal  cases,  reported  in  his  tables. 

Shock  or  collapse, 25 

Hemorrhage, 24 

Peritonitis, 64 

Phlebitis, 1 

Tetanus,      ••.......  2 

Intestinal  affections, 6 

Abscess 3 

Chest  diseases, 4 

Congestion  of  brain, 1 

Diabetes, 1 

Not  stated, 19 

150 

Here  also  peritonitis  appears  as  the  most  frequently  fatal  sequel 
of  the  operation,  then  come  shock  or  collapse,  and  hemorrhage. 
After  these  no  causes  which  are  especially  operative  are  recorded. 

Out  of  forty-five  completed  operations  by  myself  seventeen  deaths 
have  occurred  from  the  following  causes: 


4  died  of  peritonitis. 
1  "  "  rupture  of  the  pedicle  on  14th  day. 

1  "  "  pneumonia  on  2ist  da}'. 

2  "  "  constant  and  prolonged  vomiting. 
1  "  "  gangrene  of  peritoneum. 

3  "  "  shock. 

5  "  '•  septicaemia. 

That  peritonitis  is  often,  in  these  cases,  the  consequence  of  im- 
imediate  exposure  of  the  peritoneum  to  manipulation  and  atmos- 
pheric influences  there  is  no  doubt.  In  many  cases,  however,  both 
Ithis  affection  and  septicaemia,  which  the  future  will,  I  think,  prove 
to  be  a  much  more  common  cause  of  death  than  is  now  thought, 
are  undoubtedly  created  by  the  following  conditions : 

1st.  Putrefaction  of  blood  and  the  contents  of  the  sac  left  in 
the  peritoneum,  or  oozing  into  it  from  the  small  vessels  of  broken 
adhesions. 

2d.  Putrefaction  of  the  stump  distal  to  the  ligature  securing  its 
sressels.(?) 

3d.  Phlebitis  set  up  by  ligation  of  tie  veins  of  the  stump. 


726  OVARIOTOMY. 

4tli.  Pouring  of  pus  into  the  peritoneum  from  incomplete  closure 
of  the  peritoneal  lips  of  the  abdominal  incision. 

5th.  Irritation  of  the  peritoneum  by  foreign  substances,  (liga- 
tures,) left  within  it. 

If  these  propositions  be  true,  the  indications  suggesting  them- 
selves for  the  avoidance  of  danger  will  be — 

1st.  To  leave  no  fluid  susceptible  of  putrefaction  in  the  perito- 
neum. 

2d.  To  prevent  secondary  hemorrhage  by  carefully  checking  all 
flow,  before  the  abdominal  wound  is  closed,  by  ligatures,  torsion, 
the  actual  cautery,  and  persulphate  of  iron. 

3d.  To  avoid  the  flow  of  pus  into  the  peritoneum  by  uniting  the 
abdominal  wound  on  both  its  cutaneous  and  peritoneal  aspects. 

4t]i.  To  avoid  as  much  as  possible  leaving  foreign  substances 
within  the  peritoneum,  and  to  employ  the  most  innocuous  sub- 
stances as  ligatures  when  these  are  necessary. 

5tli.  To  provide  the  means  for  cleansing  the  peritoneum  before 
closing  the  abdominal  wound  whenever  putrescent  materials  are 
likely  to  collect  in  the  abdomen. 

Statistics  of  Ovariotomy. — The  time  has  passed  when  in  an  essay 
upon  this  subject  the  question  need  be  discussed  as  to  the  propriety 
of  recognizing  ovariotomy  as  a  legitimate  resource  in  surgery. 
The  operation  has  to-day  not  only  the  verbal  endorsement  of  the 
first  obstetric  surgeons  in  the  world;  it  has  the  more  positive  testi- 
mony of  their  resorting  to  it  in  dealing  with  cases  requiring  its 
aid.  So  lengthy  is  the  list  of  eminent  names  giving  it  their 
sanction,  and  so  thoroughly  has  i\\e  ground  been  investigated  by 
recent  writers,  that  I  deem  it  unnecessary  to  examine  it  more 
minutely.  But  besides  this  the  results  and  rapid  spread  of  the 
operation  in  Great  Britain  and  America,  and  of  later  years  in  Ger- 
many and  France,  may  be  pointed  to  in  reply  to  such  a  question  ; 
results  which  are  fully  as  favorable  as  those  of  other  important 
capital  operations.  Out  of  660  operations  in  America,  tabulated 
by  Peaslee,^  453  were  successful.  One  who  reads  without  reflection 
the  large  proportion  of  deaths  from  this  dangerous  surgical  pro- 
cedure is  apt  to  forget  the  evil  results  which  commonly  follow  all 
surgical  operations.  Let  them,  for  example,  be  compared  with 
those  published  by  a  committee^  of  the  medical  board  of  Bellevue 
Hospital  in  this  city  during  the  present  year.  The  period  embraced 
is  iTom  January,  1872,  to  June,  1873 :    Number  of  amputations 

'  Op.  cit.,  p.  248.  2  Report  by  Drs.  Janeway,  Sayre,  and  Loomis. 


STATISTICS    OF    OVARIOTOMY 


727 


excluding  those  of  the  fingers  and  toes,  58 ;  recoveries,  26 ;  deaths, 
28 ;  cause  of  death — 4  from  shock,  2  from  secondary  hcmorrliago, 
1  from  tetanus,  11  from  pjsemia,  1  from  hospital  gangrene,  8  from 
exhaustion,  and  1  from  osteo-myelitis.  Amputations  of  the  hand, 
5;  recoveries,  2;  deaths,  3.  Amputations  of  tlie  forearm,  4;  re- 
coveries, 3 ;  died,  1.  Amputations  of  arm,  including  shoulder-joint, 
11 ;  recoveries,  6  ;  died  5.  Amputations  of  the  thigh,  3 ;  recoveries, 
1 ;  died,  2.  Amputations  of  leg,  including  knee-joint,  28 ;  recov- 
eries, 15;  died,  13.  Amputations  of  the  foot,  8;  recoveries,  4; 
died,  4.  Amputations  for  disease,  9  ;  for  injury,  49.  In  one  case 
both  forearms  were  amputated ;  in  two  cases  both  legs,  and  in  two 
cases  both  feet. 

The  statistical  tables  of  St.  George's  Hospital,  London,  for  the 
years  1867  and  1868  were  examined  by  one  of  this  committee,  with 
the  following  results  :  Amputations,  54 ;  recoveries,  27 ;  amputations 
for  disease,  32  ;  deaths  from  pyaemia,  11.  Most  of  the  amputations 
were  of  the  tliigh,  leg,  and  foot. 

An  approximate  idea  of  the  rapidity  with  which  ovariotomy  has 
been  accepted,  may  be  obtained  from  the  statistics  collected  by 
diiferent  writers  during  the  past  ten  years: 

In  1850,  Dr.  Lyman'  collected  212  cases 

In  1860,  Dr.  J.  Clay^  '■  42.5      " 

In  1864,  Dr.  Peaslee''  raised  the  number  to    78T      " 

In  presenting  the  statistics  of  the  subject  it  is  difficult  to  do  so 
with  perfect  justice.  The  operation  is  a  recently  em})loyed  pro- 
cedure, and  although  simple  in  its  details  depends  for  success  so 
much  upon  little,  and  at  first  sight  apparently  insignificant,  points, 
that  the  statistics  of  inexperienced  operators  cannot  witli  justice 
be  admitted.  A  proof  of  this  is  offered  by  a  compai-ison  of  the 
earlier  and  more  recent  results  of  the  most  eminent  ovariotomista 
as  given  by  Prof.  Simpson: 


Dr.  C.  Clay 

in  his  first 

20 

operations  Ic 

st  1  in  2;^ 

" 

"     second 

20 

1  ••  H 

" 

"     third 

20 

1  "  4 

Mr.  S.  Wells 

"     first 

.50 

1  "  2 

<( 

"     second 

50 

1  "  3 

(( 

"     third 

50 

1  "  4 

'     Dr.  Keith 

"     first 

20 

1  "  H 

" 

"     second 

20 

1  "  6i 

Dr.  Atlee 

"     first 

101 

1  ••  n'n 

" 

"     following 

78 

1  "  3? 

'  Prize  Essav.  Mass.  Med.  Soc. 


2  Translation  of  Kiwisch  on  Ovaries. 


^  On  Ovariotomy,  Trans.  Acad.  Med.  X.  Y. 


728  OVARIOTOMY. 

Between  the  statistics  collected  in  Germany  and  those  in  Great 
Britain  and  America,  there  is  so  marked  a  discrepancy  that  one 
cannot  hut  agree  with  Dr.  Atlee,^  of  riiiladelphia,  in  this  opinion  : 
"  The  German  mortality  is  excessive,  and  there  must  he  a  fault 
somewhere.  Their  great  dread  of  making  a  free  opening  in  the 
ahdominal  cavity,  and  their  method  of  managing  the  pedicle,  may 
have  much  to  do  with  their  want  of  success."  Simon  declares 
that  out  of  sixty-one  operations  only  twelve  completely  recovered ; 
and  Scanzoni,^  in  giving  his  reasons  for  not  accepting  it,  speaks  of 
it  as  "a  procedure  hy  which  Langenheck  has  lost  five  patients  out 
of  six,  and  Kiwisch  four  out  of  five." 

Dr.  Paul  Grenser,  of  Germany,  has  recently,  after  a  six  months* 
tour  in  England  for  the  purpose  of  investigating  this  suhject,  made 
a  careful  report  of  the  results  of  his  observations.  I  quote  in 
reference  to  it  an  abstract  by  Dr.  S.  Brandeis,^  of  Kentucky: 

"  The  reason  ■nlij  English  surgeons  surpass  all  other  nations  in  the 
results  obtained  in  ovariotomj',  Grenser  believes  to  be  found  in  the  easy 
and  quiet  temperament,  with  the  hardier  and  better  nourished  systems 
of  English  women  ;  the  proper  selection  of  tlie  locality  ;  rooms  well  ven- 
tilated, on  the  second  or  third  story,  remote  from  patients  with  serious 
ailments;  the  great  variety  of  piecautionar}'  measures;  the  superior 
operative  skill  and  manipulation  ;    and  lun-ses  Avell  trained  for  the  work." 

As  it  is  not  my  intention  to  present  full  statistics  upon  ovariot- 
omy, which  would  be  out  of  place  in  a  work  of  the  character  of 
this,  but  merely  to  give  the  practitioner  certain  facts  which  will 
enable  him  to  decide  in  favor  of,  or  against,  the  operation  at  the 
bedside,  I  shall  content  myself  with  stating  the  results  ol)tained 
by  operators  who  have  become  eminent  in  connection  with  it 
during  the  past  ten  or  fifteen  years.  Of  the  following  list,  those 
who  have  operated  in  Europe  are  quoted  chiefly  on  the  authority 
of  Grenser,  whose  report  was  made  in  1871  ;  those  in  America 
mainly  from  personal  testimony.  The  statement  in  almost  all  cases 
is  brought  up  to  1871.     When  this  is  not  done  it  is  so  stated. 

For  the  purpose  of  avoiding  tcdiousness  of  detail,  the  statistics 
of  no  surgeon  who  has  performed  less  than  five  operations  are  in- 
troduced into  this  table. 

'  Gardner's  Notes  to  Scanzoni.  p.  2.^)5.  ^  Op.  cit.,  p.  471. 

^  Richmond  and  Louisville  Med.  Journ.,  April,  1871. 


CONDITIONS    FAVORABLE    TO    THE    OPERATION 


729 


Operator. 


Country. 


No.  of        Re- 
cases,   coveries.  Deaths 


Spencer  Wells I  Great  Britain      400 

Olay I       "           ■■  210 

Baker  Brown ..I        "            "  120 

Keith I       "            "  100 

Brvant2 I        "            "  28 

Willett I       "            "  2 

Tyler  Smith  (to  1806)  j       "  "         ,       17 

Niissbaum Germany  34 

Spiegelber^ "  lo 

Koeberle "  US 

Stilling "  17 

Skoldberg Sweden  21 


W.  L.  Atlee. 


Kimball 

Dunlap 

Bradford 

Peaslee 

White 

Marion  Sims 

Emmet 

Kammerer 

McRuer 

Axford 

Allen  Smith 

Noeggerath 

Turner 

Crosby 

Green 

Tewksbury 

Beebe 

Hill 

Tracy  

Gaillard  Thomas . 


138 
84 
81 
17 
4 

14 
18 
10 
42 


Sweden 
United  States 


107 

72 
36 
19 
11 


Australia 
United  States 


130 

60 

31 

26 

25 

12 

17 

5 

22 

7 

5 

6 

9 

5 

8 

7 

6 

6 

13 

27 


"1^  of  the  opera- 
tions were  suc- 
cessful." 


Authority. 


Personal  communication 

to  Dr.  Peaslee. 
Dr.  Qrenser.i 

((  II 

Lancet,  August,  1870. 
Dr.  Qrenser 
Dr.  Brandeis.' 

Dr.  Grenser.* 

Dr.  Peaslee. 

N.  Y.  Med.  Jour.  May,  1870. 

Personal  communication. 


Rd.  &  L.  Med.  .Tour.  Ap.  1871. 
Personal  communication. 


Dr.  Peaslee. 

Personal  communication. 

Dr.  Blanton. 

Personal  communication. 

Pe.islee,  ovarian  tumors. 


The  great  difficulties  attending  the  collection  of  statistics  by 
correspondence  has  deterred  me  from  bringing  these  up  to  the  date 
of  this  edition. 

Conditions  favorable  to  the  operation — 

Clearness  and  certainty  of  diagnosis ; 

Good  constitutional  condition; 

Patient  being  hopeful  and  desirous  of  operation; 

Paucilocular  character  of  cyst ; 

Absence  of  much  solid  matter  in  its  structure; 

Abdominal  walls  not  very  thick; 

Absence  of  strong  and  Avascular  adhesions. 

The  possibility  of  error  in  diagnosis  has  been  already  sufficiently 
dwelt  upon.  The  importance  of  clearly  understanding  the  nature 
of  the  tumor  cannot  be  over-estimated.  The  operator  should,  by 
repeated,  prolonged,  and    most  careful  examinations,  alone,  and 


•  Report  on  Ovariotomy  in  England,  abstract  by  Brandeis.    Richmond  and  Louis- 
ville Journ.,  April.  1871.  ^  Report  carried  np  only  to  1806. 
3  Extract  from  Swedish  table.     Brandeis.     R.  and  L.  Med.  Journ..  April.  1871. 
Report  on  Ovariotomy  in  Germany.    Pamphlet  translated  by  Grunhut. 


730  OVARIOTOMY-r 

afterwards  aided  by  others,  endeavor  to  determine  all  the  features 
of  the  case,  not  merely  the  fact  that  a  tumor  exists,  but  that  it  is 
ovarian  and  not  uterine,  that  pregnancy  does  not  exist  with  it,  that 
it  is  not  cancerous,  that  its  contents  are  fluid,  and  that  the  fluid  felt 
is  all  ovarian  and  none  of  it  abdominal.  In  two  cases  I  have,  in 
company  with  a  number  of  others  who  consulted  with  me,  been 
greatly  deceived.  In  one  case,  when  upon  the  point  of  operating 
upon  a  large,  multilocular  tumor,  the  patient  lying  on  the  table,  I 
discovered  the  coexistence  of  pregnancy  in  the  fiftli  month.  In 
another,  which  I  supposed  to  be  a  large  ovarian  tumor,  upon  cutting 
through  the  abdominal  walls,  an  inmiense  amount  of  fluid  escaped, 
leaving  for  removal  a  solid  tumor  of  the  ovary  not  larger  than  the 
adult  head.  Cases  are  on  record  in  which  surgeons  of  great  experi- 
ence and  skill  have  cut  down  upon  uterine  fibroids,  cysts  of  the 
kidneys,  the  pregnant  uterus,  and  other  growths,  under  the  impres- 
sion that  ovarian  cysts  existed,  and  instances  have  occurred  in 
which  abdominal  section  discovered  no  tumor  of  any  kind,  the 
operator  having  been  deceived  by  tympanites. 

As  to  the  period  at  which  the  operation  should  be  undertaken, 
there  is,  and  probably  always  will  be,  a  great  deal  of  diversity  of 
opinion.  As  the  decision  of  this  point  will  always  involve  a  great 
deal  of  responsibility  on  the  part  of  the  operator,  it  will  not  be 
without  interest  to  refer  to  the  views  of  the  chief  authorities  of  our 
day.  Baker  Brown  operated  quite  early,  as  soon  as  the  diagnosis 
was  fully  established,  in  order  to  avoid  changes  in  the  cyst  and  peri- 
toneum. Keith,  Peaslee,  Atlee,  and  Tyler  Smith  wait  for  some 
degree  of  impairment  of  health  and  emaciation.  Wells  operates 
when  the  patient  cannot  walk  a  mile  without  difliculty.  Bryant 
does  so  when  the  tumor  by  its  size,  inconveniences  the  patient  and 
interferes  with  her  domestic  duties,  while  Greenhalgh  postpones 
the  operation  as  long  as  it  is  justifiable,  in  order  to  secure  changes 
in  the  peritoneum  which  will  render  it  less  liable  to  traumatic 
peritonitis. 

It  appears  to  me  that  the  general  rule  should  be  this :  if  a  small 
cyst  be  discovered  which  is  removable  by  the  vagina,  it  should  be 
removed  as  soon  as  possible,  while  one  too  large  for  this  should 
be  interfered  with  when  it  is  evident  that  the  [tatient  is  failing  in 
strength,  and  becoming  emaciated,  depressed,  and  nervous. 

The  following  table,  constructed  by  Dr.  J.  Clay,  of  299  cases  in 
which  the  general  health  was  ascertained,  displays  the  important 
fact  that  even  great  emaciation  does  not  produce  a  very  unfavor- 
able result: 


CONDITIONS    UN|%V0RABLE    TO    THE    OPERATION.       731 


Class  of  cases. 

Health  good. 

Health 
impaired. 

17 

25 

Much 
emaciated. 

Complicated 

with  other 

disease. 

Comi)licated 

with 

pregnancy. 

Successful    .     .     . 
Unsuccessful     .     . 

Total     .     .     . 

21 

21 

47 
46 

21 
27 

2 
2 

42 

42 

93 

48 

4 

The  mental  state  of  the  patient  has  so  marked  an  influence  on 
the  result  that  operators  agree  that  a  depressed  and  apprehensive 
mind  commonly  produces  an  unfavorable  issue. 

The  greater  the  amount  of  solid  matter  in  an  ovarian  tumor, 
the  more  favorable  will  be  the  prognosis  as  to  rate  of  growth  and 
the  more  unfavorable  as  to  cure. 

The  following  is  Dr.  Clay's  table  in  reference  to  the  character  of 
the  tumor: 


Class  of  cases. 

IMonocystic. 

Polycystic. 

Solid. 

Small. 

Medium. 

Large. 

Successful     .     . 
Unsuccessful  •    . 

Total     .     . 

19 

25 

66 
106 

8 

13 

4 
3 

14 

17 

30 

18 

44 

172 

21 

7 

31 

78 

The  greater  the  thickness  of  the  abdominal  walls  the  more 
extensive  will  be  the  surface  which  must  unite  to  etfect  closure  of 
the  abdominal  opening,  and  the  greater  the  probability  of  suppu- 
ration occurring  between  the  lips  of  the  wound  and  pus  pouring 
into  the  peritoneum. 

The  presence  of  adhesions  to  the  abdominal  viscera  greatly  com- 
plicates the  case,  but  as  this  can  be  determined  only  after  abdomi- 
nal section,  its  consideration  will  be  postponed  until  that  point  in 
the  description  of  the  operation  is  reached. 

Conditions  unfavorable  to  the  operation. — The  following  circum- 
stances, although  unfavorable  to  the  oi)eration,  do  not  contraindi- 
cate  it  unless  they  exist  in  the  most  exaggerated  degree: 

Obscurity  as  to  diagnosis  ; 
Great  constitutional  impairment ; 
Gastric  or  intestinal  disorder ; 
Depression  of  spirits ; 
Presence  of  much  solid  matter  in  tumor ; 
Extensive  and  firm  adhesions  to  viscera ; 
Complication  with  other  diseases; 
Great  thickness  of  abdominal  walls. 


732  OVAEIOTOMY. 

Ovariotomy  is  applicable  to  cases  between  the  desperate  ones  of 
cystic  disease  susceptible  of  treatment  only  by  incision,  and  those 
not  susceptible  of  cure  by  injection  or  drainage.  It  also  offers  the 
only  hope  in  cases  of  solid  tumors. 

In  certain  cases,  rare  ones  I  admit,  in  which  a  tumor  not  larger 
than  the  head  of  a  child  a  year  old  falls  down  into  Douglas's  cul- 
de-sac,  it  will  be  i30ssible  to  cut  through  the  vagina,  seize  the  sac, 
draw  it  down,  ligate  the  pedicle,  and  return  the  stump  to  the  abdo- 
men. If  this  can  be  done  a  great  deal  of  risk  will  be  avoided,  and 
the  patient  spared  a  lengthy  period  of  suspense,  with  the  prospect 
of  a  serious  capital  operation  at  the  end.  I  have  m.ct  with  but  one 
case  in  which  I  have  resorted  to  this  procedure,  and  that  case  I 
shall  now  lay  before  the  reader  as  it  was  at  the  time  reported  for  a 
medical  journal. 

Vaginal  Ovariotomy. — Mrs.  S.,  a  multipara,  of  spare  habit  and 
remarkably  excitable  nervous  systeni,  had  suffered  for  a  length  of 
time  from  retroflexion  of  the  uterus.  For  this  she  had  been  suc- 
cessfully treated  by  Dr.  James  L.  Brown,  and  for  the  past  three 
years  had  been  entirely  free  from  any  rational  or  physical  signs  of 
the  condition  until  four  months  ago.  At  this  time  finding  a  return 
of  symptoms,  due  to  pressure  upon  the  rectum,  she  sent  again  for 
her  physician.  Dr.  Brown  examined  and  discovered  a  movable 
cyst  behind  the  uterus,  which,  in  the  erect  and  supine  position, 
pushed  the  fundus  uteri  forwards  and  occupied  Douglas's  cul-de- 
sac  completely.  This  cyst  was  equal  in  size,  when  first  discovered, 
to  a  large  orange;  was  painless  upon  pressure,  and  could  readily 
be  pushed  out  of  the  pelvic  cavity.  Dr.  Brown  made  the  diagnosis 
of  cystic  degeneration  of  the  ovary,  and  advised  the  patient  to  seek 
further  counsel. 

In  accordance  with  this  suggestion,  Drs.  Peaslee,  N^oeggerath, 
and  myself  met  in  consultation  and  carefully  investigated  the  case. 
At  this  time  we  found  everything  in  accordance  with  what  has 
been  already  stated,  and  concurred  in  the  opinion  of  Dr.  Brown, 
deciding  still  further  that  the  right  ovary  was  the  seat  of  the  disease, 
and  that  the  cyst  was  in  all  probability  multilocular. 

In  discussing  the  subject  of  treatment  three  plans  were  proposed : 
first,  that  the  cyst  should  be  allowed  to  develop  so  that  ovariotomy 
might  be  resorted  to  after  some  years  of  life  had  been  passed  in 
comparative  comfort ;  second,  that  the  cyst  should  be  tapped  per 
vaginam ;  and  third,  that  the  operation  of  ovariotomy  should  be 
performed  through  the  fornix  vaginae,  in  the  same  manner  that  it 


VAGINAL    OVARIOTOMY.  733 

18  ordinarily  accomplished  through  the  abdominal  walls.  The  last 
proposal  was  made  by  myself,  and  urged  upon  these  grounds : 

1st.  I  felt  satisfied  that,  the  cyst  being  movable,  (as  proved  by  the 
fact  that  the  knee-elbow  position  would  at  once  cause  it  to  roll 
out  of  the  pelvis,)  sufficient  space  could  be  obtained  through  the 
fornix  vaginae  to  withdraw  the  emptied  sac. 

2d.  I  preferred  this  procedure  to  simple  tapping,  because  drain- 
age is  very  apt  to  follow  paracentesis  when  practised  through  the 
vagina,  which  might  exhaust  the  patient  and  prevent  a  resort  to 
ovariotomy  at  a  later  period.  Furthermore,  I  did  not  regard  the 
increase  of  danger  attendant  upon  vaginal  section  as  very  great, 
even  if  removal  of  the  cyst  proved  impossible;  for  in  case  of  such 
an  occurrence  I'proposed  simply  to  tap  the  exposed  cyst  and  close 
the  vaginal  opening  by  silver  sutures. 

3d.  I  urged  the  adoption  of  the  vaginal  operation  rather  than  the 
alternative  of  waiting  for  the  full  development  of  the  cyst,  because 
of  the  peculiarly  anxious  nature  of  the  patient.  After  being  in- 
formed of  the  nature  of  the  disease,  she  thought  and  spoke  of  almost 
nothing  else,  lost  appetite,  slept  badly,  and  evidently  depreciated  in 
strength.  From  all  that  I  could  learn  from  her  husband,  who  is  a 
practitioner  of  medicine,  from  Dr.  Brown,  and  from  my  own  obser- 
vation, I  thought  that  she  would  prove  a  most  unfavorable  case  for 
ovariotomy  at  time  of  full  development  of  the  tumor;  and,  to  repeat  a 
consideration  just  given  in  connection  with  paracentesis,  I  regarded 
the  tentative  process  as  not  attended  by  great  risk,  since  it  involved 
incision  only  into  the  most  dependent  portion  of  the  peritoneum. 

All  these  views  were  fully  laid  before  the  patient  and  her 
husband,  and  at  the  end  of  a  fortnight  it  was  decided  that  the 
operation  should  be  attempted. 

Dr.  Brown  prepared  the  patient  for  the  operation  by  the  use  of 
cathartics  and  kept  her  upon  a  milk  diet  for  forty-eight  hours 
previous  to  its  performance.  On  Sunday,  February  6th,  1870,  at 
3  P.  M.,  I  proceeded  to  o])erate,  in  presence  of  Drs.  Peaslee,  Brown, 
Walker,  Purdy,  J.  C.  Smith,  and  Sproat. 

Dr.  Purdy  having  anaesthetized  her  with  ether,  she  was  i)lac('d 
in  the  knee-elbow  position,  and  secured  upon  the  ai)paratus  of  Dr. 
Bozemjin.  This  apparatus  not  only  completely  secures  the  [)atient 
in  this  position,  by  straps  and  braces,  but  makes  the  position  per- 
fectly comfortable  for  any  length  of  time,  and  also  favors  the  ad- 
ministration of  an  ansesthetic.     It  is  shown  in  Fig.  180. 

To  prevent  all  possibility  of  the  rectum  falling  into  the  line  of 
incision,  a  rectal  bougie  was  inserted  for  aljout  live  inches.    Sims's 


734 


OVARIOTOMY. 


specuhim  being  now  introduced,  and  the  perineum  and  posterior 
vaginal  wall  lifted,  I  caught  the  fornix  vagiuie  midway  between 
the  cervix  and  rectum  with  a  tenaculum,  drew  it  well  down,  and 
with  a  pair  of  long-handled  scissors,  one  limb  of  which  was  placed 
against  the  rectum  and  the  other  against  tne  cervix,  cut  into  the 
peritoneum  at  one  stroke. 

Fiff.  180. 


Bozemaa's  securing  apparatus. 


The  first  step  of  the  operation  being  now  accomjilished,  I  pro- 
ceeded to  the  second.  The  patient's  position  was  changed  to  the 
dorsal  decubitus,  and  passing  my  finger  through  the  vaginal  incision 
I  distinctly  touched  the  tumor,  which  had  now  fallen  again  into 
the  pelvis,  and  fastened  a  tenaculum  in  its  wall.  With  a  small 
trocar  I  then  punctured,  one  after  the  other,  three  cysts,  which  gave 
vent  to  about  six  or  eight  ounces  of  fluid  which  looked  precisely 
like  vomited  bile.  Drawing  upon  the  cyst,  it  now  passed  without 
difficulty  into  the  vagina. 

For  the  third  step  of  the  operation  the  position  of  the  patient 
was  again  changed.  She  was  now  placed  in  Sims's  position  on  the 
left  side  and  his  speculum  introduced.  Passing  through  the  pedicle 
at  its  point  of  exit  from  tlie  vaginal  roof  a  needle,  armed  with  a 
strong  double  silk  ligature,  I  tied  each  half  of  the  penetrated  tissue 
and  cut  off  the  cyst  and  ligature.  The  cul-de-sac  of  Douglas  was 
then  sponged,  the  pedicle  returned  to  the  abdominal  cavity,  the 
incision  in  the  vagina  closed  by  one  silver  suture,  and  the  patient 
put  to  bed. 

The  entire  operation  occupied  thirty-five  minutes,  and  presented 


VAGINAL    OVARIOTOMY.  735 

no  difficulties  other  than  those  slight  ones  incidental  to  li'i-ature  of 
a  pedicle  at  some  distance  up  the  vagina. 

Subsequent  to  the  operation  the  patient  was  kept  quiet  and  free 
from  pain  by  opium,  sustained  by  fluid  food,  and  strictly  confined 
to  the  supine  posture.  Her  only  discomfort  arose  from  sleepless- 
ness, and  nausea  which  followed  the  use  of  the  anaesthetic,  and  for 
ten  days  she  progressed  without  any  unfavorable  symptoms.  At 
this  time,  being  allowed  to  leave  the  bed  and  lie  upon  the  lounge, 
she  exerted  herself  unduly,  and  an  attack  of  periuterine  cellulitis 
invaded  the  right  broad  ligament.  The  pulse  became  rapid,  the 
skin  hot  and  dry,  and  a  phlegmonous  mass  as  large  as  the  fist,  hard, 
and  painful  to  the  touch,  could  be  distinctly  felt.  This  soon  began 
to  diminish,  and  at  the  end  of  the  thirtieth  day  had  ceased  to  prove 
a  source  of  any  annoyance,  while  the  general  condition  of  the 
patient  showed  her  to  be  entirely  out  of  danger. 

I  feel  confident  that  the  attack  of  cellulitis  which  complicated 
convalescence  in  this  case  was  not  at  all  dependent  upon  the  nature 
of  the  operation,  but  was  due  to  indiscretion  on  the  part  of  the 
patient  in  overrating  her  returning  strength. 

It  is  not  my  belief  that  the  scope  of  this  plan  of  performing 
ovariotomy  will  ever  be  very  great,  but  I  think  that  in  cysts  of 
small  size,  which  are  unattached,  it  will  ofi'er  a  valuable  resource 
for  the  avoidance  of  years  of  mental  suffering  while  the  disease  is 
progressing,  and  of  the  capital  operation  of  abdominal  ovariotomy 
in  the  end,  with  all  its  attendant  dangers  and  uncertainties.  Even 
in  a  doul)tful  case,  vaginal  ovariotomy  may  be  resorted  to  as  a 
tentative  measure,  which,  in  the  event  of  failure  from  attachment 
of  the  cyst,  would  in  all  probability  be  recovered  from. 

I  should  urge  upon  any  one  who  determines  to  essay  it,  not  to 
trust  to  his  general  knowledge  of  the  anatomy  of  the  fornix  vaginse 
and  peritoneum,  but  to  rehearse  the  first  step  of  the  operation  upon 
the  cadaver  before  attempting  it  upon  his  patient.  There  is  often 
considerable  space  between  the  roof  of  the  vagina  and  tlie  floor  of 
the  peritoneum,  and  it  usually  requires  two  strokes  of  the  scissors 
to  penetrate  the  abdominal  cavity.  The  first  severs  the  vagina  ; 
then  through  this  opening  a  tenaculum  should  be  passed,  and  tlie 
peritoneum  drawn  down  and  opened.  In  tliin  women,  if  the  fornix 
be  well  drawn  down  by  a  tenaculum,  one  stroke  will  often  open  thi- 
peritoneum. 

Since  the  time  of  this  operation  I  have  met  with  two  cases  to 
which  the  method  would  have  been  applicable.  In  one  the  attend- 
ing physician  withheld  his  consent  and  the  patient  was  guide<l  by 


736  OVARIOTOMY. 

his  decision.  In  the  other  the  physician  with  whom  I  saw  the  case 
preferred  to  tap  and  drain  by  the  vagina.  The  operation  has  been 
twice  repeated,  once  by  Dr.  J.  T.  Gilmore,  of  Mobile,  the  report  of 
whose  case  I  give  from  his  account,  and  that  of  Dr.  F.  B.  Hamilton, 
the  attending  physician ;  and  once  by  Dr.  R.  Battey,  of  Georgia, 
an  extract  from  whose  letter  describing  it  I  likewise  introduce. 
Dr.  Gilmore  says:^ 

"  By  elevating  the  head  and  shoulders,  I  could  distinctl}-  feel  in  the 
retro-uterine  s])aee  a  tumor  as  large  as  a  small  orange.  Your  operation  was 
fresh  in  my  mind,  and  was  advised  for  the  following  reasons:  the  woman 
had  the  habit  of  opium  eating,  acquired  because  of  the  pain  in  the  left 
ovary;  and  at  the  age  of  forty-eight,  with  her  habits  and  damaged  health, 
abdominal  ovariotomy  would  in  all  probabilitj'^  prove  fatal.  Secondly. 
Vaginal  ovariotoni}^  is  safer  than  abdominal  ovariotomy,  for  the  follow- 
ing reasons:  Through  the  vagina  the  incision  is  through  structures  that 
heal  more  readily  than  those  covering  the  abdomen.  Then  again,  the 
vaginal  incision  is  better  for  drainage.  Thirdly.  Every  practical  sur- 
geon knows,  that  the  more  remote  an  incision  into  the  abdominal  cavity 
is  from  the  diaphragm,  the  less  is  tlie  danger  from  acute  peritonitis. 
These  reasons  influenced  me  to  dissent  from  the  opinions  of  Dr.  Peaslee, 
expressed  in  his  monograph  on  Ovarian  Tumors.  The  patient,  after  ap- 
preciating her  condition,  readily  consented  to  the  operation.  I  placed 
her  in  Sims's  position,  and  after  introducing  Siras's  speculum,  seized  the 
posterior  lips  of  the  cervix  with  a  Museux  forceps,  and  drew  tiie  uterus 
gently  forwards  and  downwards.  J  then  carried  the  index  finger  of  the 
left  hand  into  the  rectum,  and  the  same  finger  of  the  riglit  hand  into  the 
vagina.  I  foiind  by  this  manoeuvre  I  had  a  vaginal  space  of  2^  inches 
through  which  to  enter  the  abdominal  cavit}-.  I  then  introduced  the 
speculum,  the  patient  being  all  this  time  chloroformed,  and  the  bowels 
having  been  thorougiily  emptied  by  a  purgative  dose  of  castor  oil.  With 
a  long-handled  tenaculum  I  seized  the  vaginal  mucous  membrane,  and 
examined  carefully  to  determine  the  absence  of  all  pulsating  vessels.  « 
Being  satisfied  on  this  point,  with  a  pair  of  curved  scissors  I  divided  the  ■] 
structures  embraced  by  the  tenaculum  longitudinally,  extending  from  a 
few  lines  posterior  to  the  uterus  to  within  a  few  lines  of  the  rectum.  J 
then  awaited  the  cessation  of  all  oozing  of  Mood.  Then  I  carefully  ex- 
plored the  line  of  the  wound,  some  two  inches  in  length,  and  found  myself 
down  upon  the  peritoneum.  By  making  firm  pressure  in  the  direction 
of  the  body  of  the  uterus  in  the  incision,  I  found  that  the  rectum  was 
out  of  the  way,  and  with  a  small-pointed  tenotome  I  punctured  the  peri- 
toneum.    This  puncture  I  enlarged  sufficiently  to  admit  the  index  finger. 


■  N.  0.  Med.  and  Surg.  Journ.,  Nov.  1873. 


I 


VAGINAL    OVARIOTOMY.  737 

Tlie  opening  into  tlie  peritoneum  I  then  enlarged,  so  as  to  correspond 
with  the  external  cut.  I  tlien  readily  introduced  the  index  and  middle 
fingers  of  the  right  hand.  I  found  I  could  explore  the  pelvic  cavity — 
could  readily  feel  the  fundus  of  the  uterus.  1  embraced  the  tumor  be- 
tween the  two  fingers.  After  pressing  firmly  upon  the  lower  part  of  the 
abdomen,  and  having  brought  it  down  until  its  lower  part  presented  at 
the  incision,  it  could  be  distinctly  seen  to  be  a  cyst.  One  of  my  assist- 
ants, Dr.  J.  M.  Collins,  punctured  it  with  a  tenotomy  knife,  and  evacu- 
ated its  contents  partl^y  ;  when  thus  lessened,  it  escaped  through  the  open- 
ing. By  drawing  upon  the  cyst,  I  dragged  out  the  ovary,  from  which 
it  grew-  by  a  peduncle.  The  ovary  contained  a  cyst  the  size  of  a  small 
marble  ;  and  the  Fallopian  tube,  which  could  be  felt  before  the  abdominal 
cavity  was  opened,  was  brought  out  with  the  cyst,  its  fimbriae  being 
spread  over  the  large  cyst.  The  peduncle  of  the  large  cyst  was  about 
cue  inch  and  a  half  in  length.  With  all  these  structures  well  drawn 
down  into  the  vagina,  I  proceeded  to  eftect  their  removal,  by  first  using 
Nott's  rectilinear  clamp.  I  passed  it  up  in  front  of  the  cyst,  and  era- 
braced  a  portion  of  the  broad  ligament  and  Fallopian  tube.  After  screw- 
ing it  tightly  down,  I  removed  it,  and  applied  at  the  crushed  point  a 
waxed  silk  ligature;  then  with  a  curved  pair  of  scissors  I  removed  the 
whole — the  left  ovary,  the  cyst,  and  the  Fallopian  tube — leaving  a  stump 
suflRcient  to  prevent  the  slipping  of  the  ligature,  which  I  left  hanging  out 
of  the  vulva,  and  to  the  distal  end  of  which  I  tied  a  piece  of  cotton  to 
prevent  it,  perchance,  from  slii)ping  into  the  abdomen.  I  finall}-  closed 
the  vaginal  opening  with  three  silver  sutures.  I  passed  one  of  the 
sutures  through  the  pedicle,  so  as  to  keep  the  stump  distal  to  the  liga- 
ture in  the  vagina I  found  the  whole  procedure  extremely 

simple  and  easy.  The  whole  operation  was  executed  without  a  change 
of  posture,  and  consumed  onl}-  about  ten  minutes." 

The  operation  was  performed  on  September  6th,  and  the  patient 
dismissed,  cured,  on  October  1st,  the  temperature  never  at  any  time 
risino;  above  100°. 

Dr.  Battey's  case  is  described  as  follows : 

"On  Monday,  March  30th,  1874,  I  cut  into  the  cul-de-sac  and  removed 
a  cyst,  the  size  of  a  small  orange,  for  a  lady  from  upper  Georgia.    Tiie  ope- 
ration was  executed  with  the  greatest  facility,  the  opposite  ovary  brought 
down  into  the  vagina,  examined,  and  returned  to  its  place.     My  patient 
I  has  not  had  an  untoward  symptom ;  her  pulse  has  not  risen  above  90, 
;  and  only  ibr  twenty-four  hours  has  it  exceeded  80.     The  ligature  i)laced 
I  upon  the  pedicle  came  away  yesterday,  April  14th,  and  to-day  an  cxplo- 
I  ration  of  the  vagina  shows  the  wound  quite  healed." 

I  feel  sure  that  this  procedure  will,  when  its  merits  have  been 
^ fairly  tested,  occupy  an  important  jilnce  in  the  treatment  of  ova- 
47 


738  OVARIOTOMY. 

rian  cysts.  It  is  fully  as  easy  of  performance  as  abdominal 
ovariotomy ;  is  evidently  attended  by  much  less  danger ;  holds  out 
to  the  patient  the  opportunity  of  avoiding  many  weary  months  of 
suspense  in  anticipation  of  that  more  grave  procedure;  i^  equally 
applicable  to  multilocular  and  to  unilocular  cysts  ;  gives  abundant 
facility  for  securing  the  pedicle  ;  and  is,  so  far  as  my  experience  and 
knowledge  go,  defensible  as  a  surgical  procedure  against  all  but 
theoretical  objections. 

Ahdoiainal  Ovariotomy. — I  have  already  expressed  my  belief  that 
only  a  limited  number  of  cases  will  be  susceptible  of  the  procedure 
just  described.  The  great  resource  in  ovarian  tumors,  is  the  ordi- 
nary operation  of  ovariotomy  l)y  the  abdomen. 

In  arriving  at  a  just  estimate  of  the  results  of  this  operation, 
two  facts  should  always  be  borne  in  mind:  first,  that  many  cases 
of  gastrotomy  have  been  reported  under  the  name  of  ovariotomy ; 
and  second^  that  a  large  number  of  true  ovarian  operations  have 
been  undertaken  in  entirely  inappropriate  cased  in  consequence  of 
erroneous  diagnosis.  By  every  one  who  examines  the  records  of 
this  sul)ject,  even  superficially,  these  two  facts  must  be  recognized 
as  very  markedly  depreciating  the  statistics  of  ovariotomy.  The 
true  and  only  meaning  which  should  attach  to  the  term  ovario- 
tomy is  the  removal  of  one  or  both  ovaries.  Gastrotomy  is  a  kin- 
dred, but  not  identical  procedure,  and  should  never  be  confounded 
with  it,  either  as  to  its  indications  or  results. 

At  present  no  progressive  gynecologist  will  question  the  propriety 
of  performing  gastrotomy  for  the  removal  of  other  than  ovarian 
tumors  when  they  threaten  life,  and  when  operative  interference 
promises  a  prolongation  of  existence  and  diminution  of  sufi^ering. 
I  am  not  considering  this  question  now,  however,  but  merely 
stating  what  all  will  admit,  that  gastrotomy  thus  performed  should 
no  more  be  classed  with  ovariotomy  than  should  the  Cesarean 
section. 

Solid  tumors  of  the  ovary  are  comparatively  rare,  and  although 
ovariotomy  may  be  occasionally  indicated  for  their  removal,  i 
may  with  propriety  be  stated  that  the  truly  legitimate  field  fa 
this  operation — the  crowning  surgical  achievement  of  our  country 
— is  the  removal  of  one  or  both  ovaries  when  afifccted  by  cystic; 
degeneration. 

The  diseases  which  have  been  most  commonly  confounded  wit 
ovarian  cyst,  and  induced  a  resort   to   gastrotomy  by  reason   o; 
erroneous  diagnosis,  are  the  following:  fibro-cystic  tumors  of  the 
uterus;  abdominal  dropsy;  colloid  degeneration,  having  for  its  base 


i 


^1 


ABDOMINAL    OVAEIOTOMY.  739 

the  peritoneum,  the  mesentery,  the  abdominal  viscera,  or,  as  I  have 
seen  in  two  cases,  the  uterus  ;  and  malignant  disease  of  the  ovaries. 
Instances  are  not  wanting  in  which  pregnancy,  phantom  tumors, 
uterine  fibroids,  cystic  degeneration  of  the  kidneys,  and  other  con- 
ditions have  given  rise  to  errors  of  diagnosis  ;  but  these  have  rarely 
done  so,  while  those  which  I  have  just  enumerated  have  frequently 
misled  operators  of  skill  and  experience.  Instances  of  these  affec- 
tions will  often  present  themselves  in  which  the  most  experienced 
diagnostician  will  be  able  to  arrive  at  a  positive  conclusion  only 
by  the  aid  of  paracentesis  or  an  explorative  incision,  and  a  certain 
number  will  be  met  with  in  which  even  with  these  means  at  his 
disposal  the  most  cautious  operator  will  be  led  into  error. 

Nothing  will  so  pow^erfully  tend  to  give  the  operation  of  ovarian 
extirpation  its  proper  and  legitimate  position  among  the  resources 
of  surgery,  and  thus  enlarge  its  sphere  of  usefulness,  as  the  acquire- 
ment of  a  skill  in  diagnosis  on  the  part  of  those  who  are  called 
upon  to  perform  it,  which  will  serve  to  point  out  with  system  and 
certainty  the  cases  to  which  it  is  peculiarly  applicable,  as  well  as 
those  for  the  relief  of  which  it  holds  out  scarcely  a  hope. 

Although  this  operation  has  now  so  fully  overcome  the  opposi- 
tion once  arrayed  against  it  as  to  have  assumed  its  position  as  one 
of  the  legitimate  resources  of  surgery,  it  is  yet  too  recent  a  pro- 
cedure, not  to  require  the  light  which  can  be  thrown  upon  it  by 
honestly  reported  statistics,  and  by  them  alone.  Amputation  of 
the  thigh  has  been  so  often  performed,  for  so  many  years,  and  in 
so  wide  an  extent  of  territory,  that  the  surgeon  who  now  i:)erforms 
it  is  excusable  if  he  does  not  report  every  case  for  the  critical  ex- 
amination of  his  peers.  All  questions  as  to  the  value  and  results 
of  the  operation  are  at  rest ;  and,  although  statistics  with  regard 
to  it  will  always  be  of  value,  the  profession  no  longer  demands 
them  as  essential  for  its  ultimate  position  as  a  surgical  resource. 
iWith  ovariotomy  it  is  otherwise.  Every  case  should  be  carefully 
and  frankly  reported,  in  order  that  it  may  serve  to  swell  the  num- 
ers  from  which  conclusions,  whether  favorable  or  unfavorable  to 
:he  procedure,  are  to  be  drawn. 

There  are  many  influences  at  work  at  present  which  tend  to 
seep  up  the  mortality  attendant  upon  this  operation.  Some  ot 
'•-hese  are  inherent  to  the  operation  itself,  and  will  always  exist ; 
)thers,  as  knowledge  increases  with  experience,  and  the  basis 
ipon  which  it  rests  becomes  more  stable  and  assured,  will  greatly 
liminish  or  entirely  disappear.  First  among  these  must  be  men- 
ioned   the  necessity  for  cutting  into   the  peritoneum,  exposing 


740  OVARIOTOMY. 

this  delicate  and  important  structure  for  a  long  time,  and  often 
leaving  vessels  open  upon  its  surface,  or  within  its  cavity,  which 
pour  out  blood  that  serves  as  material  for  putrefaction.  Second, 
the  difficulty  of  diagnosis  must  not  be  lost  sight  of.  It  is  safe  to 
say  that  in  no  pathological  condition  for  Avhich  surgical  means 
are  adopted,  is  this  difficulty  equalled.  But  it  is  not  my  intention 
to  enumerate  all  the  influences  to  which  I  have  made  allusion,  and 
I  shall  content  myself  with  the  mention  of  a  third.  The  observa- 
tion of  others  may  not  agree  with  mine,  and  many  may  dissent 
from  what  I  am  about  to  advance,  but  to  me  it  stands  forth  clearly 
as  an  influence  wdiich  has  done,  and  is  doing,  much  to  injure  the 
position  of  ovariotomy  as  a  surgical  resource.  It  is  this :  the 
operation  of  ovariotomy  is  at  present  in  this  country  often  per- 
formed by  men  inexperienced  in  the  diagnosis  and  treatment  of 
ovarian  tumors.  The  statistics  of  some  of  the  best  operators  prove 
that  they  have  been  progressively  successful,  as  they  have  advanced 
in  experience,  and  learned  to  avoid  the  dangers  attendant  upon 
the  procedure,  and  we  must  conclude  that  they  who  operate  foi- 
the  iirst  or  second  time,  must  damage  the  array  of  reported  cases 
and  increase  the  rate  of  mortality.  I  know  full  well  that  it  ma\ 
be  asked  in  reference  to  this  statement,  if  inexperienced  men  never 
operated,  where  would  our  supply  of  new  surgeons  come  from?  In 
reply  to  this  I  would  remark,  that  if  the  professional  relations  of 
any  man  make  it  likely  that  he  will  be  frequently  called  upon  to 
perform  this  or  any  other  operation,  he  should  prepare  himself  to 
meet  the  demand  upon  him;  but  I  cannot  think  it  incumbent  on 
any  practitioner,  upon  whom  no  such  demand  is  likely  to  be  made, 
to  undertake  so  formidable  an  operation  if  the  services  of  skilful 
and  experienced  men  be  attainable  for  its  performance.  I  sincerely 
believe,  as  the  result  of  observation,  that  the  third  influence  which 
I  have  stated  as  marring  the  statistics  of  the  sulyect,  is  by  no  means 
an  insignificant  one,  at  least  in  the  United  States.  ]My  impression 
is  that  if  the  histories  of  all  the  single  operations  performed  by 
different  practitioners  in  this  country  were  published,  they  would 
present  a  lengthy,  and  by  no  means  pleasing,  exhibit. 

Preparation  for  the  Operation. — We  know  that  the  septic  endo- 
metritis, which  is  the  starting-point  of  those  symptoms  which 
grouped  together  constitute  puerperal  fever,  is  often  excited  by 
the  miasm  attaching  to  the  medical  attendant  from  an  autopsy,  a 
case  of  erysipelas,  typhus  fever,  or  hospital  gangrene.  Although 
the  fact  that  these  miasms  will  exert  an  equally  baneful  influence 
on  the  jtarts  exposed  in  this  operation  is  not  proved,  it  is  at  least 


PREPARATION     FOR    THE    OPERATION.  741 

SO  probable  that  no  operator  should  expose  a  patient  to  the  test. 
It  is  true  that  in  the  one  case  a  mucous  membrane  altered  by 
pregnancy  and  parturition  is  involved,  and  in  the  other  a  seroun 
sac;  nevertheless  there  is  sufficient  probability  that  evil  might 
accrue,  to  make  us  careful  to  avoid  these  sources  of  disease. 
Previous  to  the  operation  the  patient  should  be  put  upon  a  tonic 
course.  Generous  diet,  iron,  quinine,  fresh  air,  cheerful  surrouiid- 
in2;s,  and  gentle  exe-cise  should,  unless  impracticable  from  some 
peculiarity  of  the  case,  be  prescribed.  A  visit  to  the  country  or 
some  quiet  watering  place  will  prove  of  great  advantage.  Above 
all  things,  the  mind  of  the  patient  should  be  made  calm  and  cheer- 
ful, and  every  hope  as  to  the  result  of  the  operation  encouraged. 
After  a  candid  statement  of  the  chances  of  success  has  been 
rendered  her  as  material  upon  which  to  base  her  determination  to 
accept  or  reject  the  operation,  no  doubt  ought  thenceforth  to  be 
expressed  as  to  the  result  by  physician  or  friends. 

The  operation  should  be  performed  in  a  locality  where  the  air 
is  pure  and  salubrious — never  in  the  wards  of  a  crowded  hospital, 
and  if  a  choice  be  offered,  in  the  country  rather  than  the  city. 
The  day  selected  should  be  clear,  and  neither  very  hot  nor  very 
cold.  If  the  weather  be  cool,  tlie  temperature  of  the  apartment 
should  be  kept  at  from  seventy-eight  to  eighty,  and  the  atmos- 
phere moistened  by  evaporation  of  water.  A  thoroughly  exjieri- 
enced  nurse  should  be  in  readiness  to  take  charge  of  the  patient. 

After  the  operation  it  is  essential  that  the  bowels  should  be  kept 
constipated  for  a  week  or  ten  days.  That  this  may  be  done  with- 
out inconvenience  they  should  be  empty  at  the  time  of  operation. 
To  effect  this,  during  the  week  preceding  it  they  should  be  acted 
upon  by  a  gentle  laxative  every  second  day,  and  the  patient  kept 
for  two  days  previous  to  the  operation  upon  animal  broths,  beef-tea, 
milk,  and  gruels  like  those  of  farina  or  Indian  meal. 

It  is  certainly  demonstrated  that  the  influence  of  opium  upon 
the  nervous  system  is  antagonistic  to  the  spread  and  progress  of 
peritonitis  when  once  aroused ;  why  should  it  not  be  so  likewise 
to  its  establishment?  During  the  last  two  days  before  the  ojiera- 
tion  one  grain  of  opium,  or  the  equivalent  of  some  of  its  prepara- 
tions, should  be  given  as  often  as  every  eight  hours.  This  not  only 
quiets  the  nervous  system,  but  tests  the  patient's  capability  of 
tolerating  the  medicine.  One  hour  before  operating,  Dr.  Atlee 
gives  a  dose  of  opium.  The  skin  should  be  put  into  good  condi- 
■  tion  by  warm  baths  employed  daily  for  a  week  or  more,  and  its 
temperature  kept  equable  during  the  operation  by  a  flannel  wrapper 


742  OVARIOTOMY. 

and  drawers.  As  tlie  time  for  operation  arrives,  the  bladder  should 
be  carefully  evacuated,  the  patient  ansesthetized,  and  laid  upon  her 
back  upon  a  table  of  suitable  lioight  and  strength,  which  is  covered 
by  folded  counterpanes  or  blankets,  and  placed  before  a  window 
aiFording  a  good  light. 

The  operator  will  require  live  assistants,  one  to  administer  the 
anaesthetic,  one  to  stand  opposite  to  him  and  aid  in  manipulating 
the  tumor  and  abdominal  wall,  one  to  take  charge  of  the  instru- 
ments, one  to  apply  ligatures,  the  actual  cautery,  etc.,  and  a  fifth, 
to  cleanse  and  supply  sponges. 

The  Operation. — Although  this  operation  has  of  late  j^ears  been 
so  full}^  discussed  and  so  free  an  interchange  of  sentiment  con- 
cerning it  has  been  afforded,  there  is  not  one  point  connected 
with  it  upon  which  operators  are  agreed.  The  extent  of  incision, 
management  of  pedicle,  closure  of  wound,  and  the  other  steps 
which  will  be  alluded  to,  are  still  subjects  upon  which  great 
variety  of  opinion  exists.  I  shall  avoid  discussion,  and  hoping  to 
be  pardoned  for  any  appearance  of  dogmatism  which  may  result 
from  so  doing,  give  such  a  description  as  will,  according  to  my 
view,  best  meet  the  requirements  of  practice. 

The  8te]ts  of  the  operation  are  these: — 

1st.  Incision ; 

2d.    Examination  for  and  rupture  of  adhesions  ; 

3d.    Tapping ; 

4th.  Removal  of  the  sac ; 

5th.  Securing  the  pedicle ; 

6th.  Cleansing  the  peritoneum ; 

7th.  Establishing  drainage ; 

8th.  Closing  abdominal  wound. 

The  incision  is  made  by  a  bistoury  held  by  the  operator,  who 
stands  at  the  right  side  of  the  patient.  It  should  pass  directly 
through  the  linea  alba,  and  should  extend  from  a  point  at  a  vary- 
ing distance  below  the  navel  to  one  a  little  above  the  symphysis 
pubis.  Passing  through  the  skin  and  adipose  tissue,  layer  by  layer, 
it  is  continued  until  the  operator  sees  the  fibrous  sheath  of  the 
recti  muscles.  An  inexperienced  operator  may  take  this  for  the 
peritoneum.  If  any  doubt  exist,  it  should  not  be  incised  until 
exposure  to  the  air  and  pressure  by  forceps,  fingers,  or  sponges, 
have  checked  the  venous  flow  occurring  from  the  vessels  exposed 
by  the  abdominal  incision.  Then  the  fibrous  structure  should  be 
caught   by  a   tenaculum,   snipped  with    scissors,   and   a   grooved 


THE    OPERATION.  743 

director  passed  under  it,  upon  which  it  may  be  slit.  If  this 
exjwse  the  bellj  of  one  of  the  recti,  it  will  be  evident  that  the 
linea  alba  has  not  been  struck  by  the  incision.  To  reach  it,  the 
director  should  be  pushed  under  the  sheath  across  the  muscle,  and 
it  will  be  arrested  at  the  linea,  where  the  incision  may  be  made. 
All  hemorrhage  having  ceased,  the  parietal  peritoneum  should  l)e 
lifted  by  the  tenaculum,  snipped,  and  slit  upon  the  director  for  the 
length  of  the  incision. 

It  may  be  supposed  that  no  difficulty  could  arise  in  cutting 
through  the  abdominal  walls,  but  this  is  not  so.  Operators  will 
sometimes  commit  most  serious  errors  even  here.  In  two  cases,  one 
of  which  occurred  to  myself,  and  the  other  to  a  very  skill'ul  oper- 
ator of  this  city,  the  incision  was  carried  only  down  to  the  parietal 
peritoneum,  when  this  was  stripped  away  from  tlie  muscles  under 
the  impression  that  it  was  an  attached  cyst  wall.  In  other  cases 
operators  have  become  confused  in  searching  for  the  linea  alba,  and 
in  others  still,  the  incision  which  should  open  only  the  abdomen 
lays  open  the  cyst  itself,  and  allows  its  contents  to  flow  away  pre- 
maturely. By  cutting  at  first  only  through  skin  and  areolar  tissue, 
and  then  applying  the  tenaculum  to  all  doubtful  tissues,  these  diffi- 
culties may  be  to  a  great  extent  avoided. 

As  the  peritoneum  is  slit  a  slight  flow  of  straw-colored  serum 
will  usually  take  place,  after  which  either  the  shining  wall  of  the 
sac  will  be  exposed  to  view,  or,  as  will  sometimes  be  the  case,  a 
thin  layer  of  omentum  will  be  found  spread  out  over  its  surface. 
This  should  not  be  cut,  but  lifted  like  an  apron  and  put  aside. 
Sometimes,  in  addition  to  omentum,  a  loop  of  intestine  may  be 
found  over  the  anterior  face  of  the  tumor,  as  happened  in  one  of 
Mr.  Baker  Brown's  cases,  wliere  it  would  have  been  incised  had 
the  operator  not  slit  the  peritoneum  upon  a  director  with  scissors. 

Mr.  Brown  has  laid  down,  in  reference  to  the  abdominal  section, 
this  important  rule :  it  should  always  be  regarded  originally  as  an 
explorative  incision.  If  any  condition  contraindicating  tlie  n-moval 
of  the  sac  be  found  to  exist,  it  may  then  be  closed  without  exjiosure 
of  the  patient  to  great  danger,  while  if  it  be  found  advisable  to 
enlarge  it  to  proceed,  this  may  be  done  to  any  necessary  extent. 
Mr.  Wells  has  removed  one  sac  by  an  incision  of  one  inch  and  a 
half,  and  rarely  resorts  to  one  of  over  five  inches.  On  the  otlier 
hand.  Dr.  Clay,  whose  favorable  statistics  have  been  alluded  to, 
prefers  the  long  incision.  The  great  dread  which  has  always  been 
entertained  of  cutting  into  and  exposing  the  peritoneum,  lends  a 
deo-ree  of  fascination  to  the  short  incision.     AVhen  it  is  home  in 


744  OVAKIOTOMY. 

mind  that  it  is  to  putrefaction  of  retained  fluids  that  peritonitia 
and  septic;«mia  are  chiefly  due,  this  feeling  will  diminish  in  force, 
for  it  is  evident  that  the  smaller  the  opening  the  more  difficult  will 
it  be  to  discover  and  close  bleeding  vessels,  and  to  cleanse  the 
abdominal  cavity. 

The  results  of  Mr.  Wells  as  embodied  in  the  following  table  prove, 
however,  that  short  incisions  are  greatly  to  be  preferred  to  long  ones. 

No.  of  cases.     Recoveries.    Deaths.    Mortality. 
Not  exceeding  6  in.,  440  337  103  23.4  per  cent. 

Exceeding  6  in.,  GO  36  24  40.     "      " 

It  is  equally  worthy  of  note  that  the  same  surgeon  operated  on 
17  cases  by  an  incision  of  3  inclios,  and  lost  23.53  per  cent,  and  on 
203  cases  by  an  incision  of  5  inches  and  lost  19.7  per  cent. 

The  most  rational  deduction  to  be  drawn  from  these  facts  is  this: 
that  the  shorter  the  incision  by  which  the  sac  can  be  removed 
"tuto,  cito,  et  jucunde,"  the  better  for  prognosis.  The  effort  to 
remove  the  sac,  however,  through  an  opening  so  small  as  to  involve 
delay,  uncertainty,  and  inefiicient  manipulation  gives  the  patient 
a  poorer  prospect  for  recovery  than  the  practice  of  a  freer  one 
would  offer. 

The  shining  wall  of  the  cyst,  covered  by  visceral  peritoneum, 
being  now  under  the  fingers  and  eyes  of  the  operator,  he  has  an 
opportunity  of  verifying  his  diagnosis  by  palpation,  visual  examina- 
tion, and  removal  of  fluid  l>y  a  very  snuxll  trocar  and  canula  or  by 
the  needle  of  the  hypodermic  syringe.  Should  connection  with  the 
uterus  be  suspected,  before  proceeding  further  its  relations  to  this 
organ  should  be  determined  by  passing  the  uterine  sound,  and 
rotating  the  uterus  while  two  fingers  are  passed  through  the  ab- 
dominal wound  down  to  the  fundus  uteri. 

At  this  moment  the  operator  may  be  checked  in  his  progress  by 
discovering  that  he  is  not  in  contact  with  the  cyst-wall,  although 
the  peritoneum  be  opened.  In  place  of  the  smooth  shining  wall  of 
the  cj^st  he  discovers  a  vascular  membrane  containing  large  vessels, 
which  spreads  over  the  tumor  like  an  apron.  To  one  who  has  never 
seen  this  covering  it  will  y)rove  very  perplexing.  It  consists  of  the 
peritoneal  walls  or  roof  of  the  broad  ligaments  which  have  been 
spread  out  by  the  growing  tumor  and  have  undergone  great  hyper- 
trophy. Tumors  thus  surrounded  have,  according  to  my  experience, 
broad  and  short  pedicles,  and  their  extirpation  will  be  very  difficult 
unless  the  valuable  method  advised  by  Dr.  Miner,  of  Buffalo,  N.  Y., 
be  adopted.  It  consists  in  cutting  through  the  envelope  of  the  cyst, 
avoiding,  as  far  as  possible,  the  opening  of  large  vessels,  introducing 


EXAMINATION    FOE    AND    RUPTURE    OF    ADHESIONS.       745 

the  fingers,  and  enucleating  the  turner.^  The  sac  which  is  left 
should  then  be  opened,  thoroughly  cleansed,  touched  all  over  its 
oozing  surface  with  solution  of  persulphate  of  iron,  and,  if  laro-e, 
tied  around  a  catheter  which  should  act  as  a  drainage  tube. 

Ernmination  for  and  Rapture  of  Adhesions. — The  hands,  beino; 
raY)idly  cleansed  of  blood  which  has  collected  on  them  during  the 
incision,  should  be  di2:)ped  in  a  basin  of  warm  water,  to  which  has 
been  added  one  drachm  of  the  chloride  of  sodium  to  the  pint,  or 
sixteen  grains  of  the  crystals  of  carbolic  acid,  and  two  or  three 
fingers  passed  around  the  tumor  between  the  parietal  and  visceral 
peritoneum.  Should  they  meet  with  slight  adhesions,  these  should 
be  gently  broken;  if  none  be  reached,  a  large  steel  sound,  previ- 
ously dipped  in  warm  water,  may  be  swept  around  the  tumor  as 
far  as  the  pedicle.  Special  attention  should  be  given  to  attach- 
ments to  the  liver,  large  intestines,  uterus,  and  bladder,  which  are 
of  far  greater  moment  than  those  to  the  abdominal  walls.  This 
exploration,  like  that  by  the  fingers,  may  be  made  to  rupture  slight 
adhesions,  but  those  which  are  strong  and  well  organized  should 
be  left  for  careful  examination  and  section  after  the  incision  has 
been  prolonged.  If  such  be  found,  the  short  incision  of  two  to 
three  inches  should  be  prolonged  upwards  into  the  medium  incision 
of  five  to  seven,  or  the  long  incision  of  ten  to  twelve,  the  judgment 
of  the  operator  deciding  as  to  which  is  needful.  If  by  a  short 
incision,  and  the  means  of  exploration  already  mentioned,  the 
absence  of  adhesions  can  be  decided  on,  nothing  more  is  necessary, 
lor  this  step  of  the  operation  is  complete;  but  if  it  be  found  neces- 
sary, the  incision  should  be  prolonged,  and  the  whole  hand  passed 
into  the  peritoneal  cavity,  in  order  that  all  the  relations  of  the 
tumor  may  be  clearly  ascertained. 

The  requisite  incision  having  been  made,  as  soon  as  all  flow  from 
the  severed  vessels  has  ceased,  the  operator  should  break  all  adhe- 
sions within  reach  by  carefully  peeling  ott'  their  attachment  to  the 
tumor.  Great  care  must  ha  observed  not  to  tear  the  cyst-wall,  lest 
escape  of  its  contents  or  hemorrhage  should  occur  into  the  peri- 
toneum. In  this  way  only  moderate  adhesions  should  be  broken. 
Those  of  very  firm  and  vascular  character  should  be  dealt  with 
after  tapping.  The  patient  may  then,  according  to  the  suggestion 
of  Dr.  Hutchinson,  be  turned  on  one  side,  in  order  to  cause  the  tumor 


'  I  liave  resorted  to  this  motliod  a  number  of  times,  with  gnod  results,  in  cases 
which  would  have  proved  unmanajroahle  l)y  other  means.  It  appears  to  me  to  he 
)ne  of  the  most  valuable  of  all  the  contributions  to  ovariotomy  which  have  enjanat.-d 
rem  this  country. 


746  OVARIOTOMY. 

to  protrude  through  the  incision,  and  the  fluid  removed  by  tapping 
to  pour  out  of  and  not  into  the  abdomen.  I  have,  however,  given 
up  tliis  plan,  for  the  reasons  that  it  complicates  the  operation,  and 
renders  escape  of  intestines  with  the  fluid  and  tumor  exceedingly 
probable.  A  little  care  in  drawing  ofi:'  the  fluid,  and  proper  com- 
pression of  the  abdominal  walls  by  assistants,  will  usually  serve  to 
prevent  entrance  of  fluid  into  the  peritoneal  sac. 

Tapping. — If  doubt  exist  as  to  the  character  of  the  tumor,  it 
should  now  be  tapped  with  an  exploring  trocar,  for  a  tumor  sup- 
posed to  be  fluid  may  thus  be  proved  to  be  solid,  without  involving 
flow  of  blood  into  the  peritoneum.  If  this  exi)lorative  puncture 
prove  the  tumor  to  contain  fluid,  a  large  trocar  like  that  of  Spencer 
Wells,  represented  in  Fig.  181,  may  be  plunged  in,  fixed  to  the 

Fiff.  181. 


Si)encer  Wells's  trocar  and  canula. 

wall  of  the  cyst  by  its  wings,  and  the  fluid  allowed  to  pour  out  into 
an  appropriate  vessel  through  a  caoutchouc  tube  attached  to  the 
mouth  of  the  canula.  A  large  trocar  should  never  be  emi)loyed 
until  it  is  absolutely  certain  that  the  tumor  is  an  ovarian  cyst,  and 
that  the  prospects  are  decidedly  in  favor  of  its  susceptibility  of 
removal.  After  the  insertion  of  a  small  trocar,  retreat  from  extir- 
pation is  much  easier  and  safer  than  after  that  of  a  large  one. 

While  the  fluid  is  pouring  out,  compression  of  the  abdominal 
walls  against  the  tumor  should  be  made  by  an  assistant,  who  places 
one  hand  on  each  side  of  the  abdominal  incision,  and  the  sac  should 
be  kept  from  slipping  into  the  abdomen  by  strong  forceps  made  to 
grasp  its  lips,  if  an  ordinary  canula  be  employed. 

When  the  cyst  is  nearly  or  quite  empty,  and  before  search  is 
made  for  remaining  sacs,  the  fingers  or  a  pair  of  Pinkham's  Avire 
retractors  should  be  fixed  in  the  upper  commissure  of  the  abdo- 
minal incision,  and  the  abdominal  walls  be  held  up  and  open  so  as 
to  allow  a  large  space  to  exist  between  them  and  the  wall  of  the 
half-empt}^  sac.  Looking  into  this  the  operator  will  now  readily 
see  any  existing  adliesions,  and  break  them  with  his  fingers  or  the 


REMOVAL    OF    THE    SAC.  747 

handle  of  a  scalpel.  By  this  means  he  may  avoid  the  necessity  of 
enlarging  his  incision,  and  succeed  in  breaking  adhesions  for  a 
considerable  distance  up  the  sac-wall.  This  being  done,  the  main 
sac,  the  flow  from  which  has  been  meantime  controlled  by  the 
fingers  of  an  assistant  or  by  forceps,  should  be  completely  emptied, 
the  cannla  removed,  and  the  index  linger  introduced  in  order  to 
ascertain  tlie  existence  of  other  cysts.  A  good  deal  of  time  is 
often  lost  in  an  attempt  to  plunge  the  trocar  into  these,  and  some- 
times the  hand  is  introduced  into  the  peritoneum  to  seize  and 
steady  them.  The  following  method  I  have  always  found  very 
useful,  expeditious,  and  safe.  The  sac  being  seized  by  strong 
tenacula  or  forceps,  one  on  each  side  of  the  opening  made  by  the 
trocar,  it  is  cut  into  so  as  to  admit  the  hand,  which  finds  the 
remaining  sacs  and  readily  guides  the  trocar  to  them.  All  the  large 
cysts  being  emptied,  the  operator  should  at  once  proceed  to  the 
removal  of  the  sac. 

Removal  of  the  Sac. — The  sac,  being  now  drawn  out  l)y  the  tooth 
force};s,  tenacula,  or  pincers,  Avhich  have  been  fixed  in  it  to  prevent 
its  escape  into  the  abdomen,  is  seized  by  the  fingers  of  the  operator 
or  assistant,  and  gently  drawn  forth  through  the  incision.  If  an 
adhesion  which  has  resisted  the  manual  efi^brts  alread}'  made  to 
rupture  the  attachments,  hold  it  in  the  abdomen,  this  should  be 
fully  exposed,  and  severed  by  detaching  it  from  the  cyst-wall  by 
the  fingers,  which  will  now  reach  it  readily;  by  the  actual  cautery, 
as  suggested  by  Mr.  Brown,  if  it  be  long  enough  to  avoid  cauteri- 
zation of  the  abdominal  wall;  by  scissors,  if  a  cutting  instrument 
must  be  used ;  or  by  a  small  ecraseur,  if  it  can  be  applied.  No  rule 
can  be  given  as  to  the  best  method,  for  each  case  will  require  tlie 
plan  specially  adapted  to  its  peculiar  features.  This  maxim  must 
be  constantly  borne  in  mind — that  plan  is  best  which  severs  attach- 
ments without  injuring  viscera  or  leaving  bloodvessels  oiieii,  for 
these  are  the  two  evils  to  be  feared.  If  a  flow  of  blood  follow  tlie 
severance  of  an  adhesion,  the  bleeding  vessel  should  be  exjiosed  and 
■igated  or  freely  touched  with  persulphate  of  iron,  or  with  the 
actual  cautery  so  lightly  as  not  to  create  a  slough. 

By  the  means  recommended,  adhesions  may  generally  be  seven  d 
without  the  application  of  ligatures,  but  now  and  then  this  is 
necessary.  If  it  be  so,  silk  should  be  unhesitatingly  employed  as  a 
method  of  ligation.  Metallic  ligatures  are  unwieldy  and  unreliable, 
and  none  of  the  other  animal  ligatures  compare  i'avorably  with  silk. 
In  some  cases  the  cyst  adheres  so  strongly  to  some  vi-eiis  that  it 
cannot  be  separated.     Under  these  circumstances  a  portion  of  the 


748 


OVARIOTOMY. 


cyst-wall  should  be  cut  out  and  allowed  to  remain  upon  the  surface 
to  which  it  so  pertinaciously  clings.  M.  Boinet'  points  out  the 
propriety  of  removing  the  secreting  surface  of  such  a  piece  before 
leaving  it.  The  tumor  being  freed  from  attachments  is  now  drawn 
forth,  and  the  jiedicle  seized  in  the  lingers.  At  this  point  there  is 
usually  a  delay  caused  by  the  lapse  of  time  required  by  the  operator 
for  determination  as  to  the  plan  which  will  be  best  adapted  to 
s'/curing  the  pedicle.  There  is  often,  too,  some  time  spent  in  dis- 
cussion upon  this  point,  for  no  operator  should  be  wedded  to  any 
single  plan  which  he  adopts  in  all  cases.  If  the  sac  be  left  attached 
to  the  pedicle  during  this  time,  it  is  greatly  in  the  way,  drags 
heavily,  soils  the  clothing,  and  usually  forces  entrance  of  its  con- 
tents into  the  abdomen,  I  have  been  in  the  hal)it  of  rai)idly  encir- 
cling the  mass  some  inches  from  the  pedicle  with  a  bit  of  fishing- 
cord,  cutting  off  the  sac,  and  then  at  leisure  examining  the  jicdicle. 
Dr.  B.  F.  Dawson  has  devised  for  this  purpose  the  temporary  clam]» 
shown  in  Fig.  182.     By  this  the  vessels  of  the  pedicle  are  secured, 


Fiff.  182. 


Dawson's  roinporary  clamp 


and  this  part  compressed  circularly  instead  of  laterally,  while  it  is 
secured  oy  the  means  which  are  to  be  permanent. 

Securing  the  Fedide.~Th\s,  which   constitutes  one  of  the  most 
important  steps  of  tiie  operation,  is  at  times  easily  and  satisfae-    j 
torily  accomplished,  while  at  others  it  is  invested  with  great  diffi- 
culties.    Unless  the  pedicle  be  excessively  short,  the  sac  may  be 
drawn  outside  of  the  abdomen  and  its  pedicle  gras[.ed  by  the 

'  New  York  Med.  Record,  July  1,  1867. 


SECURING    THE    PEDICLE.  749 

fingers.  AVhen  very  short  it  lias  to  be  manipulated  in  the  abdomen. 
It  may  be  managed  after  one  of  the  following  methods,  that  one 
being  selected  which  best  meets  the  requirements  of  the  particular 
case. 

1st.  The  pedicle  may  be  constricted  by  a  clamp  and  held  outside 
of  the  abdominal  cavity. 

2d.  The  pedicle  may  be  securely  ligated  and  held  between  I'lii- 
lips  of  the  wound  by  pins  or  sutures. 

3d.  The  pedicle  may  be  transfixed  by  double  ligatures,  which 
being  cut  short,  it  is  dropped  into  the  pelvic  cavity. 

■4th.  The  tumor  may  be  enucleated. 

5th.  The  pedicle  may  be  constricted  by  a  temporary  clamp  and 
severed  by  the  actual  cautery. 

A  large  number  of  other  methods  have  been  advised  and  practised, 
and  to  those  interested  in  the  matter,  I  would  recommend  the  work 
of  Dr.  Peaslee  on  Ovarian  Tumors  where  they  are  considered  at 
length.  I  mention  here  only  those  which  appear  to  me  deserving 
of  special  consideration  and  unquestionable  reliance. 

The  prevention  of  hemorrhage  by  the  ligature  and  clamp  is 
evidently  identical  in  principle.  The  clamp,  however,  has  the 
advantage  of  being  simpler  and  more  easily  applied.  The  clamp 
most  commonly  used  is  that  of  Mr.  Wells,  though  many  others  are 
equally  applicable.  It  is  thus  employed :  the  pedicle  or  neck  of  the 
tumor  being  held  in  the  fingers,  the  clamp,'  Fig.  183,  is  adjusted  so 

Fiff.  183. 


.-O 


/y 


X 


-->ir 


Spencer  Wells's  clamp. 


that  one  limb  passes  over  one,  and  the  other  over  the  other  side  of 
it;  the  two  branches  are  then  closely  approximated  so  as  to  oblite- 


'  Mr.  Wells  has  devised  another  clamp  since  the  introduction  of  this.  but.  as  ex- 
perience with  both  leads  me  to  regard  the  later  one  as  the  more  imperfect  of  the 
two,  I  do  not  delineate  or  describe  it. 


750 


OVARIOTOMY. 


rate  the  vessels,  and  the  sac  is  amputated  above  tliis  by  a  bistoury. 
The  clamp  is  then  laid  flat  upon  the  abdomen  and  the  incision 
closed. 

Although  this  clamp  in  the  hands  of  its  eminent  originator,  and 
in  those  of  others,  has  accomplished  grand  results,  it  has  certain 
inherent  disadvantages  connected  with  it.  The  chief  of  these  con- 
sists in  spreading  out  the  pedicle  instead  of  consolidating  it  or 
rendering  it  circular.  Attempts  have  been  made  to  overcome  this 
objection,  by  first  ligating  the  pedicle  and  then  applying  the 
instrument,  and  by  the  construction  of  other  clamps,  such  as  those 

Fiff.  184. 


French  clani]). 

of  Koeberl^  and  Atlee,  a  French  instrument.  Fig.  184,  whose  in- 
ventor I  cannot  learn,  and  the  clamp  of  Dawson,  Fig.  185. 


Fijr.  185. 


Dawson's  permanent  clamp. 

When  the  ligature  is  emploj^ed  in  the  extra-peritoneal  method, 
the  sac  is  amputated  and  the  stump  placed  between  the  lips  of  the 
wound  and  transfixed  by  large  pins,  or  the  sutures  which  close 
this  part  of  the  incision. 

Dr.  Tyler  Smith  was  instrum.ental  in  rendering  popular  a 
method  which  was  practised,  according  to  Dr.  Peaslee,  as  long  ago 
as  1829,  by  Dr.  Rogers,  and  afterwards  by  Dr.  Billington,  of  this 
city.     It  consists  in  ligating  the  stump,  cutting  both  ligature  and 


SECURING    THE    PEDICLE.  751 

pedicle  as  short  as  possible,  returning  them  to  the  abdomen,  and 
closing  the  abdominal  incision.  In  this  way  Dr.  iSniith'  operated 
upon  seventeen  cases,  and  lost  only  three  patients.  Dr.  Peaslee, 
^\'hose  success  as  an  ovariotomist  has  been  excellent,  says  of  the 
method:  "I  now  again  refer  to  Dr.  Tyler  Smith's  method  of  treat- 
ing the  pedicle  as  the  best  of  all  methods,  and  the  one  to  which 
all  others  will,  in  my  opinion,  ere  long  give  place."  At  the  same 
time  that  I  do  not  agree  with  Dr.  Peaslee  in  his  high  estimate  of 
this  plan,  I  do  so  still  less  with  those  who  entirely  repudiate  it 
and  rate  as  excessive  the  dangers  of  leaving  silk  in  the  peritoneal 
cavity.  By  theoretical  reasoning  it  is  true  that  the  practice  can 
be  made  to  appear  very  objectionable,  but  it  is  not  theory  which 
should  decide  us  in  reference  to  so  grave  a  matter.  The  results  of 
13ractice  should  outw^eigh  all  theory,  and  no  one  should  yield  aught 
to  prejudice.  This  unwarrantable  j;)rejudice  against  the  leaving 
of  silk  in  the  peritoneum,  for  so  I  regard  it,  has  been  strengthened 
by  the  report  of  34  cases  of  ovariotomy  by  Spencer  Wells  f  of 
these,  4  were  treated  by  return  of  ligature  to  the  abdomen,  and 
all  died ;  30  were  treated  by  clamp,  and  all  recovered.  Peaslee, 
whose  statistics  are  17  recoveries  out  of  26  operations;  Tyler  Smith, 
v/ho  reports  14  successes  in  17  operations ;  and  Bradford,  who  has 

I  saved  28  out  of  31  cases,  all  employ  this  plan  universally.  I 
confess  that  I  once  shared  in  the  prejudice  to  which  I  have  made 
allusion,  but  experience  has  caused  me  to  change  my  mind  with 
regard  to  it.  In  five  cases  in  which  I  performed  double  ovariot- 
omy, eight  of  the  pedicles  were  tied  with  silk  and  returned  to  the 
abdomen,  while  in  one  case  six  bleeding  vessels  of  the  omentum 
were  ligated  by  it,  yet  all  recovered.  I  do  not  regard  ligation  and 
return  as  being  as  safe  as  external  treatment  of  the  pedicle,  but  do 

jiiot  facts  prove  conclusively  that  the  prejudice  against  the  method 
\s  in  the  minds  of  many  operators  unjustifiably  great? 

Koeberl^,  of  Strasbourg,  employs  the  clamp  when  the  pedicle 
is  long,  but  when  short,  he  compresses  the  stump  by  a  species  of 
constrictor  which  tightens  a  metallic  wnre  that  surrounds  the  pedicle. 
Enucleation  will  never  prove  applicable  to  a  large  number  of  cases, 
for  where  a  pedicle  can  be  treated  by  any  of  the  methods  thus  far 
mentioned,  it  will  offer  no  advantages.  Where,  however,  there  is 
no  pedicle,  it  presents  itself  as  a  most  valuable  resource,  nnd  comes 
into  use  in  a  class  of  cases  to  which  no  other  plan  is  applicable. 


'  His  statistics  are  brought  only  up  to  1866. 
2  Loud.  Mcil.  Times  and  Gaz.,  Nov.  28,  1868. 


752 


OVARIOTOMY. 


1^0  rule  can  be  given  with  reference  to  a  choice  between  all 
these  methods  othej  than  this:  when  the  pedicle  is  long  and 
slender  it  does  not  appear  to  matter  very  much  which  plan  is 
selected,  for  all  have  yielded  and  are  daily  yielding  excellent 
results ;  but  when  it  is  very  short  the  external  does  not  promise 
nearly  so  well  as  the  internal  method  of  managing  the  stump. 

As  to  the  special  cases  for  applying  the  different  plans,  the  fol- 
lowing suggestions,  not  rules,  may  be  of  service : 

a.  The  clamp  is  applicable'  to  long  f)edicles,  requiring  powerful 
ligation,  and  presenting  a  large  amount  of  tissue  for  suppuration 
and  decay. 

h.  The  third  method  is  applicable  to  tumors  with  pedicles  too 
short  for  treatment  by  the  clamp. 

c.  Enucleation  gives  a  method  of  removal  of  tumors  which  have 
no  pedicles. 

d.  Baker  Brown  introduced  the  plan  of  amputating  the  tumor 
by  means  of  the  actual  cautery,  and  claimed  the  astonishing  results 

Fiff  186. 


Storer's  clamp-shield. 

of  twenty-nine  cures  in  thirty-two  operations.  The  insecurity 
against  hemorrhage  attendant  upon  the  method  will  probably  pre- 
vent its  competing  wi^h  those  already  mentioned,  but,  in  certain 


OBSTACLES    TO    REMOVAL    OF    SAC. 


753 


rare  cases  in  which  the  part  to  be  amputated  is  deep  within  the 
pelvis,  it  oft'ers  great  advantages.  In  doing  this,  Storer's  clamp- 
shield.  Fig.  186,  answers  a  good  purpose  in  controlling  hemorrhage, 
and  protecting  surrounding  parts. 

When  it  is  decided  to  return  the  ligated  pedicle  to  the  abdominal 
cavity  several  animal  substances  may  be  selected  for  constrictino- 
material.  Among  these  are  horsehair,  catgut,  and  silk.  Of  these 
I  greatly  prefer  the  last,  as  being  much  more  manageable  and 
efficient,  and  equally  innocuous. 

An  objection  to  the  use  of  the  ligature  cut  short  and  re- 
turned to  the  peritoneal  cavity  has  been  raised  upon  theoretical 
grounds — namely,  that  gangrene  of  the  portion  of  the  stump  distal 
to  the  ligature  was  likely  to  occur,  and  prove  a  source  of  septicae- 
mia. Spiegelberg  and  Waldeyer  have  proved  that  after  the  appli- 
cation of  a  ligature  upon  the  horns  of  the  uterus  the  portions  of 
tissue  distal  to  them  do  not  become  gangrenous,  but  are  encapsulated 
by  eifused  lymph. 

The  statement  just  made  as  to  its  being  immaterial  whether  the 
pedicle  is  returned  or  not,  in  ordinary  cases,  is  based  upon  the 
comparative  results  of  those  who  do  not  return  it,  with  those  of 
other  operators  who  do. 

The  following  analysis  of  a  large  number  of  cases  is  given  with 
reference  to  this  point  by  Dr.  J.  Clay: 


Class  of  cases. 

stated  left 
within  tlie 
abdomen. 

Inferred 
left  with- 
in the 
abdomen. 

76 
97 

Kept          Tied  in 
without    1     two  or 
by  various        more 
methods,     portions. 

Simi)ly 
ligatured. 

Stitched 

in 
wound. 

flcraseur 

used  to 

divide  it. 

Successful  . 
Unsuccessful 

Total   .     . 

118 

58 

20            122 
25              57 

22 
26 

3 

3 

2 
1 

171 

173 

45       \     179 

48                6 

3 

Obstacles  io  Removal  of  Sac  which  may  be  discovered  as  the  Opei-a- 
tion  proceeds. — There  may  be  no  pedicle,  especially  in  cases  of  solid 
or  semi-solid  tumors,  an  indissoluble  union  existing  with  the  body 
of  the  uterus.  At  other  times  the  sac  is  in  part  bound  down  so 
that  it  cannot  be  removed,  while  \)i\rt  of  it  can  be  drawn  out  of 
the  abdominal  incision.  Under  tliese  circumstances  I  have  found 
the  follownng  plan  of  great  service.  The  operator  cutting  through 
the  sac  passes  his  hand  and  arm  in  and  discovers  the  lowest  portion 
of  the  sac.  Then  nenr  the  base  of  the  sac  he  picks  up  the  perito- 
neal covering,  cuts  through  it,  passes  in  his  finger,  and  removes 
48 


754  OVAKIOTOMY. 

the  tumor  by  enucleation,  after  the  method  of  Miner  already  al- 
luded to.  The  pouch  thus  left  sometimes  fills  with  blood,  which 
being  confined  to  it  and  not  entering  the  peritoneum  presents  an 
odd  and  puzzling  appearance.  Bj  such  a  tumor  I  was  once  much 
puzzled  and  delayed  until  one  of  my  assistants  suggested  the  true 
explanation  of  it.  In  another  case  in  which  I  practised  this  method  a 
fatal  issue  occurred  in  the  following  way  :  the  patient  did  well  until 
the  fourteenth  day,  when  becoming  angry,  she  jumj^ed  from  her  bed, 
struck  violently  at  an  attendant,  fell  back  and  was  dead  in  an  hour 
and  a  half.  An  autopsy  revealed  the  fact  that  the  pouch  left  by 
enucleation  was  filled  with  a  fetid,  grumous  mass  of  blood.  The 
eftbrt  made  by  the  patient  caused  a  rupture  of  this  sac  and  escape 
of  its  contents  into  the  peritoneum,  which  produced  death  from 
collapse.  This  danger  could  be  avoided  by  thorough  checking  of 
all  oozing  of  blood  by  persulphate  of  iron  before  ligating  the  mouth 
of  the  sac,  or  by  leaving  within  it  a  drainage  tube  and  ligating 
the  neck  around  this,  and  securing  it  by  pins  in  the  wound.  By 
this  means  antiseptic  injection  could  be  regularly  practised. 

I  am  very  confident  that  I  have  succeeded  by  this  plan  of  enu- 
cleation in  extirpating  cysts,  which  could  by  no  other  means  have 
been  completely  and  safely  removed.  I  urge  its  merits  upon  the 
attention  of  operators,  for  there  is  a  class  of  cases  in  which  the 
pedicle  is  short,  wliere  it  will  prove  of  great  value. 

Sometimes  the  whole  sac,  in  consequence  of  strong  adhesions  to 
the  abdominal  viscera,  cannot  be  removed.  When  this  is  so,  that 
portion  which  is  drawn  out  should  be  removed,  the  lips  of  the  part 
remaining  be  stitched  carefully  to  the  abdominal  walls,  and  the 
incision  closed  except  at  its  lower  angle,  which  should  be  kept 
free  by  the  insertion  of  lint,  or  a  glass  tube  by  which  disinfecting 
fluids  may  be  thrown  in  to  prevent  septicaemia,  as  in  ordinary 
drainage.  This  procedure  is  a  modification  of  the  ojx'ration  of 
incision  already  alluded  to.  The  omentum  may  be  adherent  to 
such  an  extent  that  its  removal  becomes  necessary.  When  this 
involves  considerable  rupture  of  its  bloodvessels,  it  may  be  cut 
oft'  by  the  ecraseur  and  its  bleeding  extremity  touched  with  per- 
sulphate of  iron  or  the  actual  cautery ;  or  it  may  be  amputated 
and  brought  outside  the  wound,  as  is  done  in  the  case  of  the 
pedicle. 

Before  proceeding  to  the  next  step  of  the  operation  the  remain- 
ing ovary  should  always  be  carefully  examined  as  to  the  existence 
of  disease,  for  if  cystic  degeneration  exist,  it  ought  at  onc^  to  be 
removed.     If  very  minute  cysts  exist,  not  larger  than  marbles, 


ESTABLISHING    DRAINAGE.  755 

for  example,  they  should  be  incised,  but  if  large  ones  are  found, 
secretion  from  the  walls  of  which  might  cause  sufficient  flow  into 
the  peritoneum  to  excite  peritonitis  or  septicaemia,  they  should  be 
removed,  for  the  great  dangers  of  the  operation  have  already  been 
incurred,  and  it  would  be  unwise  to  leave  the  seeds  of  another 
tumor  to  develop. 

Cleansivg  the  Peritoneuya. — The  sac  having  been  removed  and 
hemorrhage  checked,  all  fluids  contained  in  the  peritoneal  cavity 
should  be  carefully  removed  by  soft  sponges  squeezed  out  of  warm 
water.  Not  only  the  intestines  and  abdominal  walls,  but  espe- 
cially the  pelvis  should  be  completely  and  thoroughly  cleansed. 
This  is  a  point  of  great  importance,  and  may  decide  the  issue  of 
the  case.  Every  particle  of  fluid  left  will  undergo  decomposition, 
and  expose  to  the  great  dangers  of  septicemia  and  peritonitis. 

Establishing  Drainage. — Xo  one  familiar  with  ovariotomy  will 
to-day  doubt  the  assertion  that  the  two  factors  which  prove  most 
fatal  after  it,  septicaemia  and  peritonitis,  are  both  in  great  degree 
due  to  the  retention  of  putrescent  materials  within  the  peritoneal 
cavity.  These  materials  may  have  escaped  from  the  cyst  during 
or  before  the  operation,  may  consist  of  blood  or  serum  oozing  from 
vessels  while  the  operation  proceeds,  or  some  hours  after  it  has 
ended,  or  arise  from  emptying  of  pus  into  the  peritoneum  from  in- 
flammatory action.  The  importance  of  not  only  preventing  the 
entrance  of  such  elements  into  the  peritoneum,  and  of  removing 
them  before  closing  the  abdominal  opening,  but  also  of  giving  them 
free  vent  during  the  period  of  convalescence  has  attracted  the  atten- 
tion of  many  ovariotomists.  Peaslee  introduced  the  plan  of  leaving 
a  cloth  tent  in  the  lower  angle  of  the  wound  in  order  to  facilitate 
drainage  in  case  of  the  development  of  septicaemia.  Koeberl^  not 
only  inserted  channels  of  metal  through  the  abdomen,  but  even 
opened  through  the  cul-de-sac  of  Douglas  and  inserted  tubes,  so  as 
to  drain  per  vaginam,  and  Sims  more  recently  has  urged  this  plan 
as  one  very  greatly  calculated  to  diminish  the  liability  to  these  con- 
ditions. 

The  removal  of  the  cloth  tent,  fixed  between  the  lips  of  the 
wound  by  congealed  blood,  is  often  ditficult  and  painful,  and  the 
passage  of  a  catheter  or  other  tube  down  into  Douglas's  cul-de-sac, 
the  most  dependent  part  of  the  peritoneum,  is  not  rarely  impossi- 
ble after  a  slight  effusion  of  lymph  has  occurred. 

Drainage  per  vaginam  by  means  of  tubes  passed  up  into  the  peri- 
toneum is,  I  think,  calculated  to  increase  the  dangers  of  ovariotomy, 
by  opening  a  way  for  putrid  fluids  from  the  peritoneum  into  the 


756 


OVARIOTOMY 


Fijr.  187. 


pelvic  cellular  tissue.  I  have  practised  it  twice  and  seen  it  adopted 
many  times,  and  it  is  upon  the  evil  results  thus  far  observed  at 
the  Ledside  that  I  base  my  estimate  of  its  value. 

It  is  my  uniform  habit  to  insert  a  glass  drainage  tube  eight 
inches  long,  and  varying  in  diameter  from  half  to  three-quarters 
of  an  inch,  just  above  the  pedicle  and  into  the 
depths  of  Douglas's  pouch,  in  every  case  except 
where  there  is  absolutely  no  fluid  left  in  the  perito- 
neum.    Fig.  187  shows  the  tube  employed. 

Should  no  fluid  be  left  in  the  abdominal  cavity 
this  tube  should  not  be  inserted,  or  if  the  operator 
be  in  doubt  it  should  be  placed  in  position  and  kept 
tightly  corked.  If  fluid  accumulation  exist,  or  its 
occurrence  be  rendered  probable  by  slight  oozing 
from  broken  adhesions,  the  tube  should  be  left  un- 
corked, that  serum  and  blood  may  drain  away.  K 
no  increase  of  temjierature  mark  the  occurrence  of 
septic  absorption,  nothing  more  is  necessary  than  to 
keep  this  in  place  until  all  danger  has  passed  aAvay. 
Should  septicaemia  show  itself  a  gum-elastic  catheter 
cut  off  near  its  end  should  be  inserted  as  far  as  pos- 
sible, the  glass  tube  drawn  up  for  an  inch,  and  a 
stream  of  warm  water  containing  one  drachm  of 
chloride  of  sodium  and  sixteen  grains  of  the  crystals 
of  carbolic  acid  to  the  pint,  gently  injected  by  means  of  a  Davidson's 
or  fountain  syringe.  No  force  whatever  should  be  employed,  but 
a  free  supply  of  water  should  be  thrown  in  until  the  return  current 
comes  forth  clear.  I  use  this  method  in  all  cases,  except  in  those 
rather  rare  ones  in  which  the  peritoneum  is  left  free  of  fluids  of 
all  kinds.  In  no  instance  have  I  known  this  tube  to  excite  inflam- 
mation. It  is  usually  left  in  place,  being  withdrawn  and  reinserted 
occasionall}' ,  for  eight  or  ten  clays,  although  I  have  kept  it  in  much 
longer  in  some  cases. 

Closing  ike  ^Youlyl. — This  is  accomplished  by  two  sets  of  sutures, 
the  dee})  and  superficial.  The  first,  composed  of  silver,  are  passed 
in  the  following  manner:  a  thread  of  silver  wire  is  passed  at  each 
of  its  extremities  through  a  long  and  stout  straight  needle.  One 
of  the  needles,  being  grasped  by  strong  needle-forceps,  is  passed 
through  the  peritoneum  of  one  al)dominal  flap  near  the  edge  of  the 
incision  and  made  to  emerge  through  the  skin  about  an  inch  from 
the  edge.  Then  the  other  needle  is  seized  and  passed  through  the 
other  side.      The  suture  is  then  secured  by  twisting.      If  it  be 


Thomas's  glass 
drainag(3  tube. 


AFTER-MANAGEMENT.  757 

desired  to  use  quilled  sutures,  it  can  be  accomplished  by  passing  a 
doubled  silver  thread  after  the  same  method.  These  deep  sutures, 
placed  at  the  distance  of  half  an  inch  apart,  will  bring  the  whole 
incision  into  contact  from  the  peritoneum  to  the  skin,  and  favor 
healing  by  first  intention. 

Another  excellent  method  is  to  pass  through  both  walls  of  the 
abdomen  a  long  needle  with  fixed  handle  and  an  eye  near  its  point 
armed  with  a  short  loop  of  silk  as  recommended  by  Peaslee.  Into 
this  loop  or  into  the  eye  of  the  needle  a  bit  of  metallic  wire  is  fitted 
and  immediately  drawn  into  place. 

Besides  these,  superficial  sutures  or  pins  like  those  employed  for 
harelip  should  be  used,  which  pass  through  the  skin  and  areolar 
tissue,  but  do  not  involve  the  peritoneum.  Around  them  thread  is 
wrapped  in  figure  of  8. 

After  this  the  abdomen  should  be  swathed  in  broad,  long  bands 
of  adhesive  plaster  to  oppose  tlie  succussion  of  vomiting.  Should 
hemorrhage  have  existed  when  the  abdominal  wound  was  closed, 
folded  towels  should  be  placed  under  these  over  the  abdominal 
muscles  to  act  as  compresses. 

Then  a  sheet  of  soft,  dry  cotton  should  be  laid  over  the  whole, 
the  patient  given  a  dose  of  opium  or  one  of  its  salts,  and  covered  up 
warmly  in  bed  with  warmth  to  the  feet  even  in  hot  weather. 

After-Management. — The  apartment  should  be  kept  at  a  tempera- 
ture of  65°  to  68°  Fahr.,  and  thorough  ventilation  secured,  not  by 
the  unpleasant  method  of  admitting  cold,  damp,  and  chilling  air, 
but  by  the  more  philosophical  one  of  causing  the  rapid  escape  of 
foul  air.  This  can  best  be  done  by  lighting  a  fire  in  tlie  chimney, 
by  immediate  removal  of  oftensive  substances,  and  by  general 
cleanliness. 

A  quiet,  attentive  nurse  who  understands  the  use  of  the  catheter 
should  be  in  attendance  day  and  night. 

The  eftect  of  the  operation  upon  the  nervous  system  should  be 
guarded  against  by  the  m.eans  just  enumerated  as  general  rules  of 
management,  and  by  administration  of  stimulants,  as  wine,  brandy, 
or  champagne,  if  the  strength  appear  to  be  failing.  In  addition, 
the  most  complete  quietude  of  mind  and  body  should  be  aftbrded. 
All  conversation  and  noise  should  be  interdicted,  tlie  ]iatient'8 
hopefulness  excited  and  fostered,  and  all  muscular  effort  avoided. 
For  four  or  five  days  the  catheter  should  be  employed  for  evncuat- 
ing  the  bladder,  and  the  bowels  be  kept  constipated  by  opium  for 
ten  days  or  a  fortnight.  The  avoidance  of  cathartics  during  this 
time  is  essential  to  safety,  a  neglect  of  this  precaution  often  pro- 


758  OVARIOTOMY. 

ducing  a  fatal  issue.  Some  years  ago  I  was  present  at  the  removal 
of  an  immense  cystic  sarcoma  by  Dr.  John  O'Reilly,  who  made  an 
incision  extending  from  the  xiphoid  cartilage  to  the  symphysis, 
and  after  detaching  many  adhesions  extirpated  the  mass.  The 
patient  did  perfectly  well  for  a  week,  and  was  in  a  fair  way  to 
recover.  She  was,  however,  very  urgent  that  her  bowels  should 
be  moved,  and  the  doctor  refusing  to  comply  with  her  solicitations, 
she  took  surreptitiousl}^  a  full  dose  of  bitartrate  of  potash.  This 
acted  as  a  hydragogue  cathartic,  but  its  action  was  not  limited  as 
it  usually  is.  Diarrhoea,  and  soon  dysentery,  supervened  and 
destroyed  the  patient's  life. 

After  the  seventh  or  eighth  day,  tympanites  may  call  for  an 
alvine  evacuation,  which  may  be  eftected  by  an  ordinary  injection 
of  soapsuds  or  an  infusion  of  linseed,  chamomile,  or  fennel. 

The  patient  should  be  kept  quiet  and  free  from  pain  by  opium, 
given  either  by  the  mouth  or  rectum,  so  soon  as  she  has  rallied 
from  the  anaesthetic ;  or,  in  case  of  great  suffering,  by  the  hypo- 
dermic method.  Her  nourishment  should  consist  of  milk,  beef- 
tea,  or  gruel  with  milk.  Even  these  digestible  substances  should 
be  given  in  small  amounts  and  with  caution.  Should  there  be  a 
tendency  to  nausea  and  vomiting,  pieces  of  ice  may  be  held  in  the 
mouth  or  swallowed,  and  if  these  symptoms  be  so  severe  as  to 
threaten  rupture  of  the  sutures,  the  hypodermic  use  of  morphia 
should  be  resorted  to. 

The  evils  which  are  chiefly  to  be  feared  as  sequels  of  the  opera- 
tion are,  within  the  first  twenty-four  hours,  hemorrhage ;  from 
second  to  fourth  day,  peritonitis;  from  completion  of  operation  to 
third  or  fourth  day,  nervous  prostration  ;  and  from  fourth  to  four- 
teenth day,  septicaemia. 

Should  hemorrhage  be  ascertained  to  be  taking  place,  all  dressing 
should  be  at  once  removed,  and  the  stump,  if  out  of  the  abdomen, 
securely  ligated  or  touched  with  the  actual  cautery.  If  it  have 
been  returned  to  the  abdominal  cavity,  there  is  but  one  course 
available,  that  is,  opening  the  wound,  ligating  the  bleeding  vessel, 
and  cleansing  the  peritoneal  cavity.  Such  a  necessity  is  very 
unfortunate,  yet  this  course  holds  out  the  only  prospect  of  success. 

Septicaemia,  which  I  believe  will  in  time  be  admitted  to  be  the 
most  frequent  cause  of  death  after  ovariotomy,  is,  when  once  fully 
established,  a  most  dangerous  state.  It  is  ushered  in  by  dizziness; 
excessive  muscular  prostration;  anorexia;  great  pallor;  high  tem- 
perature; small,  rapid,  and  very  weak  pulse;  sometimes  a  low  deli- 
rium ;  dry  tongue ;  and  a  sweetish  odor  of  the  breath.    It  is  probably 


AFTER-MANAGEMENT.  759 

this  condition  which  is  so  often  alluded  to  as  a  "typhoid  state"  after 
operations,  and  one  cannot  but  suspect  that  many,  if  not  most,  of 
those  cases  quoted  in  Dr.  Clay's  tables  as  shock  or  collapse,  occur- 
ring as  late  as  the  fifth,  sixth,  seventh,  and  tenth  days,  were  really 
instances  of  this  affection.  In  one  of  my  fatal  cases,  already  alluded 
to,  the  patient  was  doing  quite  well  on  the  evening  of  the  seventli 
(lay.  On  the  morning  of  the  eighth  I  was  struck  by  her  Avild, 
maniacal  expression  and  cadaverous  countenance ;  upon  examina- 
tion I  found  all  the  symptoms  of  septicaemia  present,  and  she  very 
soon  succumbed  to  them. 

The  gravity  of  this  sequel  has  rendered  all  operators  anxious  to 
possess  the  means  to  avoid  or  remedy  it.  Most  of  the  methods  of 
avoidance  have  been  already  stated,  the  importance  of  the  subject 
will,  however,  excuse  my  again  referring  to  them  as — 

1st.  Completely  cleansing  the  peritoneum; 

2d.  Checking  hemorrhage  before  closing  the  abdominal  wound ; 

3d.  Establishing  drainage,  whenever  fluids  are  likely  to  collect 

in  the  peritoneum; 
4th.  Mummifying  the  stump  by  persulphate  of  iron. 

Septicaemia  being  the  result,  first,  of  the  decomposition,  and 
second,  of  the  absorption,  of  fluids  in  the  peritoneum,  is  not  likelj- 
to  occur  for  several  days,  but  it  may  take  place  in  two  or  three 
weeks  after  the  operation. 

The  development  of  peritonitis  and  septicaemia  should  be  care- 
fully looked  for.  All  the  vital  and  physical  signs  which  mark 
them  should  be  constantly  investigated,  and  their  inception  b(; 
met  by  appropriate  therapeutic  means.  A  written  record  of  pulse 
rate,  temperature,  and  number  of  respirations  should  be  system- 
atically kept,  an  entry  being  made  as  to  the  three  conditions  at 
least  as  often  as  every  six  or  eight  hours.  In  case  a  competent 
assistant  remain  at  the  bedside,  it  may  be  done  more  frequently, 
but  never  often  enough  to  annoy  or  harass  the  patient. 

After  the  lapse  of  twelve  hours,  in  consequence  of  the  anpesthetic, 
the  vomiting  which  this  commonly  induces,  and  the  effect  of  a 
capital  surgical  operation  upon  the  nervous  system,  the  pulse 
usually  runs  up  to  110  or  even  120,  and  the  temperature  to  102°  or 
103°,  but  as  the  irritative  influence  of  these  agencies  passes  off  a 
subsidence  ordinarily  occurs,  the  pulse  ranging  from  90  to  105,  and 
the  temperature  from  99°  to  101°  as  convalescence  proceeds. 

If  at  any  time  the  temperature  should  gradually  or  suddenly- 
advance  to  103°,  104°,  or  105°,  except  just  as  the  patient  rallies  from 


760 


OVARIOTOMY. 


the  immediate  efiects  of  anaesthesia  and  operation,  fears  should  be 
entertained  that  peritonitis  or  septicjiemia  is  developing.  If  it 
occur  within  four  days  after  operation,  it  is  likely  to  be  the  former. 
If  after  that  time,  the  probabilities  are  greatly  in  favor  of  the  latter. 
The  pulse  will  usually  become  rapid  at  the  same  time  which-ever 
morbid  condition  is  developing,  and  it  must  not  be  forgotten  that 
the  two  are  often  combined. 

I  have  already  stated  that  in  all  cases  in  which  fluid  remains  in 
the  peritoneal  cavity  or  collects  there  subsequent  to  operation,  it  is 
my  invariable  practice  to  pass  to  tlie  very  bottom  of  Douglas's  cul- 
de-sac  the  glass  tube  elsewlicre  shown,  and  through  this,  should 
the  temperature  run  up,  to  inject  warm  water  containing  enough 
carbolic  acid  to  impart  a  taste  to  it,  and  about  one  drachm  of 
chloride  of  sodium  to  the  pint,  once  or  twice  in  every  twenty-four 
hours.  In  no  instance  have  I  seen  evil  result  from  this  course. 
Even  where  a  tube  has  not  thus  been  left  in  place,  when  the  tempe- 
rature or  pulse  rises  and  the  other  symptoms  of  septicfemia  develop, 
such  an  injection  should  be  practised  once  in  every  eight  hours. 
But  without  the  tube  left  from  the  time  of  operation,  it  is  difficult 
and  sometimes  impossible  to  reach  the  most  dependent  part  of  the 
peritoneum,  and  hence  I  urge  its  employment. 

The  following  tabulated  record  of  temperature  taken  by  Dr. 
Kuentzler,  in  a  desperately  bad  case  of  double  ovariotomy  occur- 
ring in  my  practice,  will  show  what  marked  variations  may  occur, 
what  elevations  may  be  reached  and  yet  the  patient  recover,  and 
how  decided  is  sometimes  the  effect  of  antiseptic  injections  into  the 
peritoneal  cavity  in  rapidly  lowering  the  animal  heat. 


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Let  no  one  suppose  that  septicemia  once  established  becomefe. 
irremediable.  Experience  disproves  this;  it  is  the  prolongation  of 
exposure  to  absorption  of  septic  elements  that  constitutes  the  great 
danger  of  the  condition.  "The  two  greatest  discoveries,"  says  Dr. 
Carl  Both/  "which  science  owes  to  Virchow  are,  in  my  opinion, 
the  established  independent  life  of  the  animal  cell,  and  the  important 
fact  that  the  living  blood  cannot  hold  or  retain  septic  or  putrid 
liquids,  unless  it  is  constantly  nourished  with  such  substances  from 
a  nidus  of  degeneration  and  dcca3\" 

This  method  of  meeting  in  an  efficient  and  satisfactory  manner 
the  most  fruitful  source  of  danger  after  ovariotom}',  I  regard  as 
second  in  importance  to  no  other  imja'ovement  which  has  been 
introduced  since  the  discovery  of  the  operation  itself.  It  emanated 
from  Dr.  E.  R.  Peaslee,  and  has  even  now,  T  think,  not  assumed  its 
legitimate  position  in  the  scale  of  importance. 


'  Boston  Gynaecological  Journal  for  1869,  p.  356. 


762  OVARIOTOMY. 

It  is  a  matter  of  moment,  in  reference  to  this  method,  to  l^:no^^ 
how  an  experience  of  fifteen  years  in  its  use  should  have  affected 
its  originator  towards  it.  In  an  article  written  in  1870,  he  arrives 
at  the  following  conclusions. 

"  1.  Intra-peritoueal  injections  of  water,  with  the  addition  of  liq.  sodse 
chlorinat.  or  carbolic  acid,  as  before  explained,  are  entirely  safe  after 
ovarioLomy  in  the  conditions  requiring  them. 

"2.  They  should  be  used  with  a  curatioe  intention  in  all  cases  of  sep- 
ticaemia already  developed,  and  in  all  cases  for  prevention  where  it  is 
feared,  from  the  presence  already  of  a  fluid  ih  the  peritoneal  cavity,  whose 
decomposition  Mill  produce  it. 

"3.  Thus  used,  the}'  will  diminish  the  percentage  of  deaths  from  sep- 
ticaemia after  ovariotomy  from  one-sixth  (seventeen  and  eleven-seven- 
teenths per  cent.)  of  all  who  die  after  it,  to  one-thirty-siXth  (two  and 
sixteen-seventeenths  per  cent.) ;  and  increase  the  average  success  of  ovari- 
otomy from  seventy  to  seventy-four  or  seventy-five  per  cent. 

"4.  Jiitra-peiitoneal  injections  are  never  to  be  thought  of  except  for 
the  purpose  of  jemoving  a  fluid  already  in  the  peritoneal  cavity,  which 
either  already  has,  or  assuredly  will  have,  produced  septicaemia. 

"  5.  A  tent  may  be  inserted  for  two  to  four  days  at  the  lower  end  of 
the  incision,  with  entire  safety,  in  any  case  of  ovariotomy  where  the  ac- 
cumulation of  such  fluid  is  apprehended. 

"6.  Finally,  septicjieraia  would  more  rarely  occur  after  ovariotomy  if 
all  fluid  were  removed  from  the  peritoneal  cavity  by  the  most  careful 
sponging  before  closing  the  incision." 

Peritonitis,  which  proves  the  cause  of  death  in  about  one-quarter 
of  all  who  die  from  this  operation,  is  best  avoided  by  leaving  as 
few  ligatures  as  possible  in  the  peritoneal  cavity,  by  removal  of  all 
putrefactive  matters,  and  by  keeping  the  abdominal  viscera  at  rest 
by  preventing  vesical  and  rectal  action  and  applying  a  bandage. 

Should  peritonitis  develop  early,  and  be  evidently  a  result  of 
operative  interference  with  the  peritoneum,  and  not  of  putrefaction 
of  fluids  left  within  its  cavity,  it  should  be  at  once  treated  by  free 
and  steadily  continued  use  of  opium,  after  the  plan  of  Alonzo 
Clark.  Tlie  bowels  should  be  kept  strictly  constipated,  the  patient 
perfectly  quiet  upon  the  back,.,the  diet  be  restricted  to  milk,  and 
no  other  medicine  than  opium  be  administered.  A  diflerence  of 
opinion  exists  as  to  the  benefit  arising  from  applications  over  the 
abdomen.  Mine  is,  that,  as  a  rule,  stupes  of  turpentine,  bladders 
of  ice,  and  warm  poultices,  alike  do  harm.  In  cases  where  the  dis- 
'  ease  is  limited  to  the  pelvis  the  last  often  do  good,  but  in  general 
peritonitis  the  comfort  of  the  patient  appears  to  be  favored  by  an 
avoidance  of  them. 


\ 


AFTER-MANAGEMENT.  763 

Should  peritonitis  arise  after  the  lapse  of  four  or  five  days,  it 
should,  I  think,  although  I  express  the  opinion  with  great  reserva- 
tion, be  looked  upon  as  probably  due  to  putrefaction  of  contained 
fluids,  and  be  treated  in  its  very  inception  by  peritoneal  injections. 
Should  it  arise  still  later,  for  instance,  about  the  tenth  or  twelfth 
day,  it  should  be  looked  upon  as  a  result  of  discharge  into  the 
peritoneum  of  encapsulated  fluid  material,  and  should  likewise  be 
met  in  this  way  if  injection  can  be  accomplished  without  reopen- 
ing the  abdominal  wound.  It  is  to  avoid  this  necessity  that  I  so 
commonly  employ  a  drainage  tube. 

As  to  the  time  at  which  the  sutures  should  be  removed  no  fixed 
rule  can  be  given,  for  it  will  depend  upon  the  rapidity  and  com- 
pleteness of  union.  Should  union  by  first  intention  occur,  some 
of  them  may  be  removed  on  the  sixth,  seventh,  or  eighth  day. 
But  great  care  should  always  be  observed,  and  only  those  at  points 
where  the  union  is  strong  should  be  withdrawn.  After  with- 
drawal the  abdomen  should  be  firmly  supported  by  adhesive  plaster. 
The  clamp,  if  employed,  or  the  ligature,  if  passed  out  through  the 
wound,  should  be  removed  when  they  lose  their  hold  by  reason  of 
sloughing,  and  drop  away.  No  traction  should  be  applied  to  them. 
A  case  v/as  recently  reported  before  a  society  in  London  in  which 
too  early  removal  of  the  clamp  had  resulted  in  obstinate  protrusion 
of  a  knuckle  of  intestine,  which  produced  fatal  peritonitis.  Mr. 
"Wells  used  it  as  a  text  by  which  to  urge  that  the  clamp  should 
always  be  left  in  place  until  it  was  ready  to  drop  oS.  This  will 
usually  be  about  the  eighth  or  tenth  day. 

The  patient  should  be  cautioned  against  rising  too  early  after 
convalescence.  Even  after  she  is  able  to  go  about  she  should  be 
very  careful  not  to  make  any  violent  eflforts,  and  for  a  year  or  two 
she  should  wear  a  well-fitting  abdominal  corset  to  guard  against 
ventral  hernia.  I  have  had  this  occur  in  two  cases.  The  ab- 
dominal walls  were  separated  over  a  space  measuring  about  four 
inches,  and  the  intestines  were  supported  only  by  skin,  areolar 
tissue,  and  peritoneum.  In  one  case  these  yielded  to  pressure,  and 
ouQ  year  after  ovariotomy  a  tumor  about  the  size  of  a  kidney,  with 
a  mass  of  attached  omentum,  escaped. 


764  DISEASES    OF    THE    FALLOPIAN    TUBES. 


CHAPTEK    XLVII. 

DISEASES  OF  THE  FALLOPIAN  TUBES. 

Anatomy. — The  identity  of  structure  of  the  Fallopian  tuhes  and 
uterus  will  be  appreciated  by  the  study  of  the  formation  of  these 
organs  in  the  embryo,  as  described  by  recent  observers,  more  espe- 
cially by  Leukart,  Thiersch,  and  Kcilliker. 

In  the  walls  of  the  Wolffian  body,  situated  near  the  kidneys,  on 
each  side,  in  the  female  embryo,  a  narrow  canal  develops  which 
ends  below  in  the  two  horns  of  the  uterus,  while  the  distal  ex- 
tremity performs  "a  movement  of  rotation  from  before  backward, 
and  from  above  downward  ;  the  whole,  together  with  the  liga- 
ments of  the  ovaries  and  the  round  ligaments,  being  enveloped  in 
double  folds  of  the  peritoneum,  which  enlarge  with  the  growth  of 
the  parts  themselves,  and  constitute  finally  the  broad  ligaments  of 
the  uterus."*  Coming  together  .at  the  median  line  these  canals 
coalesce,  or  undergo  fusion,  forming  the  lower  portion  of  the 
uterus,  and  the  entire  vagina  down  to  the  hymen.  The  fundal 
arch  is  now  formed  in  all  }irol)ability  from  fusion  progressing  from 
below  upwards,  although  this  is  somewhat  doubtful.  Thiersch^ 
thinks  from  observations  on  the  embryos  of  sheep  that  it  occurs 
from  below  upwards;  while  Kcilliker,  who  experimented  on  those 
of  cattle,  believes  that  it  occurs  from  the  centre.  Prof.  Dohm, 
who  experimented  upon  embryonic  foxes,  sheep,  pigs,  and  cattle, 
concludes  that  it  begins  between  the  middle  and  lower  third,  and 
extends  upwards  and  downwards.  All  this  occurs  very  early  in 
embryonic  life ;  according  to  Dohm  it  is  completed  by  the  end  of 
the  second  month.  From  the  fact  of  this  identity  of  structure 
there  naturally  exists  between  these  organs  a  close  sympathy  in 
health  and  in  disease. 

In  the  adult  woman,  accordino;  to  Carl  Henniff,^  the  riffht  tube 
is  nine  and  a  half  centimeters,  (three  centimeters  make  an  inch,) 

'  Treatise  on  Human  Physiolo<Ty,  by  J.  C.  Dalton,  p.  645. 

2  Prof.  Dohm,  of  Marburg.  Transac.  Insbruck  Convention,  Obstet.  Jouru.,  vol. 
iii.  p.  167. 

"  Uterine  Catarrh.     Translation  in  Obstet.  Jourii.,  vol.  iii,  p.  468. 


ANATOMY.  765 

while  the  left  measures  only  eight  and  a  half.  The  abdominal 
extremity  has  attached  to  it  five  large  and  ten  small  fimbriae.  Tlie 
walls  of  these  tubes  consist:  1st.  Of  peritoneum,  which  covers  them 
to  the  fimbriated  extremities.  2d.  Of  connective  tissue,  in  which 
are  interspersed  two  sets  of  muscular  fibres,  external  or  longitudinal, 
and  internal  or  transverse,  which  are  continuations  of  the  muscular 
tissue  of  the  uterus  and  broad  ligaments.  At  the  point  where 
these  tubes  enter  the  uterus,  Hennig  declares  that  the  longitudinal 
and  transverse  layers  of  fibres  both  become  greatly  developed,  and 
that  the  latter  forms  here  a  distinct  spliincter  tubce.  3d.  We  find 
within  and  lining  the  tube  a  mucous  membrane,  which  is  thrown 
into  large  and  small  folds,  which  are  very  evident  near  the  fimbri- 
ated extremity,  and  gradually  become  insignificant  as  we  advance 
towards  the  uterus.  Within  this  membrane  Mr.  Bowman  discov- 
ered tubal  glands,  wliich  consist  of  grape-like  structures,  extending 
downwards  towards  the  subjacent  muscular  fibre.  They  difier 
from  the  nmciparous  follicles  of  the  vagina,  the  Nabothian  glands 
of  the  cervix,  and  from  the  utricular  follicles  of  the  uterine  cavity. 
Ivcilliker  denies  the  existence  of  these,  but  Ilennig^  describes  them 
ver}^  fally.  These  compound  glands  of  the  Fallopian  tubes  are  lined 
with  an  epithelium  of  basement  form.  The  mucous  membrane 
covering  over  the  tubes,  and  not  dipping  down  into  these  glands, 
is  covered  by  a  ciliated  epithelium,  the  broom-like  action  of  which 
is  exerted  towards  the  uterus.  The  object  of  tliis  seems  to  be  to 
sweep  the  products  of  the  ovaries  into  the  uterus,  and  to  force  in 
the  same  direction  menstrual  blood  oozing  into  the  tubes  from  their 
mucous  lining,  as  a  result  of  ovulation.  The  zoosperms,  which  are 
known  to  pass  through  the  uterus  and  proceed  as  far  as  the  ovaries, 
are  themselves  endowed  with  powerful  ciliary  action  in  the  single 
cilia  which  each  possesses,  and  by  this  they  overcome  the  opposing 
force  of  the  tubal  cilise. 

It  is  highly  probable,  to  say  the  least,  that  the  erectile  condition 
induced  in  the  mucous  membrane  of  the  uterus  and  tubes  by  con- 
traction of  the  middle  coat  of  their  muscular  fibres  produces  in  the 
latter,  as  in  the  former,  rupture  of  bloodvessels  and  consequent 
liemorrhage.  Hennig  declares  that  "  during^  menstruation  through- 
out its  entire  surface,  it  (the  mucous  membrane  of  the  tubes)  assumes 
I  dark  red  color."  Ruysch,  an  old  anatomist  of  Amsterdam,  who 
wrote  in  1737,  describes  a  post-mortem  examination  in  Avhich  lie 
iiscovered  the  Fallopian  tubes  containing  blood.     This  has   by 

•  Loc.  cit.,  p.  473.  *  Loc.  cit.,  p.  470. 


766  DISEASES    OF    THE    FALLOPIAN    TUBES. 

some  of  the  writers  upon  the  history  of  hematocele  been  construed 
into  a  record  of  that  affection,  but  the  passage  appears  to  refer 
merely  to  a  condition  which  depends  upon  ovulation.  Messrs. 
Bernutz  and  GoupiP  mention  instances  of  the  collection  of  blood 
in  the  Fallopian  tubes  in  consequence  of  obstruction  of  these  canals. 
Dr.  Duncan^  admits  that  some  blood  may  come  from  the  tubes  in 
natural  menstruation.  In  two  of  my  cases  of  ovariotomy  in  which 
I  employed  the  clamp,  the  patients  menstruated  regularly  through 
the  tube  for  three  periods,  when  at  the  same  time  menstruating 
per  vaginam.  The  abdominal  opening  then  closed,  and  the  dis- 
charge was  thereafter  confined  to  the  vagina.  Other  cases  of  the 
same  kind  are  on  record.  ISTow,  as  in  these  cases  there  was  >Vee  exit 
of  blood  per  vaginam,  there  can  be  no  reason  for  believing  that  a 
regurgitant  action  occurred.  The  blood  flowing  by  the  tube  was 
more  probably  the  result  of  hemorrhage  into  that  canal,  the  uterine 
end  of  which  was  constricted  by  traction,  effected  by  the  confine- 
ment of  the  abdominal  end  in  the  wound. 

The  diseases  by  which  the  Fallopian  tubes  may  be  affected  are 
the  following: 

Inflammation ; 

Stricture; 

Distention ; 

Displacements. 

Inflammation  of  the  tubes,  or  salpingitis^  consists  in  inflammation 
of  their  mucous  membrane,  and  may  be  either  acute  or  chronic. 

The  acute  variety  generally  results  from  puerperal  endometritis, 
or  from  gonorrhoea,  which  has  extended  through  the  uterine  mucous 
membrane.  I  have  twice  seen  this  disease  almost  destroy  life  by 
attacking  the  uterine  mucous  membrane,  and  subsequently  pro- 
ducing pelvic  peritonitis,  doubtless  reaching  the  peritoneum  by 
traversing  the  tubes. 

Chronic  salpingitis  is  one  of  the  sources  of  uterine  leucorrhoea, 
and  commonly  produces  permanent  interference  with  the  calibre 
of  the  tubes.  In  some  cases  it  results  in  constrictions,  while  in 
others  it  produces  dilatation.  The  latter  condition  it  probably  is 
which  produces  the  discrepancy  observed  between  the  reports  of 
various  observers  as  to  the  dangers  resulting  from  intra-utcrine 
injections.  When  the  sphincteric  action  of  the  sphincter  tubse  of 
one  or  both  sides  is  destroyed,  fluid  thrown  into  the  uterus  will 
sometimes   enter   the   tubes,   and   produce    in   them   contraction, 

'  Op.  cit.,  vol.  i.  *  Fecundity,  Fertility,  and  Sterility,  p.  388. 


INFLAMMATION    OF    THE    TUBES,    OR    SALPINGITIS.       767 

spasm,  and  violent  acute  salpingitis,  which  may  go  on  to  the  pro- 
duction of  peritonitis  and  death.  When  dilatation  has  occurred  it 
is  not  at  all  rare  for  the  uterine  sound  to  be  passed  for  several 
inclies  up  the  tube.  I  have  met  with  several  unquestionable  cases 
of  this  kind.  I  say  unquestionable,  because  the  sound  must  have 
followed  one  of  two  courses,  through  the  fundus  into  the  peritoneum, 
or  up  the  canal  of  one  of  the  tubes. 

As  this  subject  has  created  some  discussion,  I  will  rapidly  allude 
to  two  of  these  cases. 

A  physician  near  this  city  wrote  to  me  concerning  the  case  of 
his  wife,  who  had  chronic  corporeal  endometritis  of  several  years' 
duration.  Upon  using  the  sound,  he  was  alarmed  at  finding  it 
pass  into  the  uterus  nearly  six  inches.  The  lady  came  down  to 
me,  and  upon  repeated  measurement  I  found  the  sound  pass  a 
little  over  three  inches.  The  patient  went  home,  when  her  hus- 
band, surprised  at  my  results,  used  the  sound  again,  when,  as 
before  in  his  hands,  it  passed  in  over  five  inches.  To  solve  the 
paradox  he  at  once  came  down  with  her,  and  when  examining 
with  him  I  distinctly  showed  him  the  normal  measurement,  a  little 
over  three  inches,  and  then  twice  passed  the  sound  up  one  tube  a 
distance  of  two  inches. 

One  of  my  clinical  assistants  pointed  out  to  me  at  my  clinique, 
as  a  fit  subject  for  a  lecture,  a  patient  whose  ^uterus  measured  five 
inches,  and  who  presented  no  symptoms  except  those  of  ordinary 
uterine  catarrh.  I  had  occasion  to  examine  this  patient,  after 
stating  this  measurement,  before  the  class,  when  I  found  that  the 
sound  passed  only  three  inches.  Confident,  from  the  well-knovt-n 
accuracy  of  my  assistant,  that  he  could  not  have  erred,  I  at  once 
stated  to  the  class  what  I  believed  to  be  the  cause  of  the  discrep- 
ancy, and  in  its  presence  passed  the  probe  up  the  right  tube,  making 
a  measurement  of  five  inches.  To  avoid  all  chance  of  error,  I  now 
requested  my  assistant  to  verify  my  two  measurements,  when  he 
also  passed  it  first  three  inches  to  the  fundus  uteri,  then  two  inches 
up  the  right  tube.  Hildebranclt'  relates  two  cases  in  which  he 
passed  a  probe  up  the  tube,  and  similar  instances  are  recorded  1  y 
Veit,^  Alatthews  Duncan,^  ISToeggcrath,^  and  others. 

The  great  danger  in  both  acute  and  chronic  salpingitis  is  pelvic 
peritonitis,  which  may  spread  and  destroy  life.    This  arises  in  part 


'  Barnes's  Report  on  Midwifery,  Brit,  and  For.  Med.-Chir.  Review,  Oct.,  18G8. 

*  New  York  Obstet.  Journ.,  vol.  i,  p.  267. 
^  Edinburgh  Mrd.  Jonrn.,  1856. 

*  Remarks  before  Obstetrical  Society,  New  York. 


768  DISEASES    OF    THE    FALLOPIAN    TUBES. 

from  escape  of  the  contents  of  the  inflamed  tubes  into  the  perito- 
neum. 

Of  the  symptoms  very  little  can  be  said.  The  chronic  variety 
may  continue  for  years,  and  result  in  dilatation  of  the  tube  with 
no  symptoms  which  arrest  attention ;  while  the  acute  form  so 
quickly  produces  local  peritonitis,  that  its  symptoms  are  lost  in 
those  of  that  affection. 

No  special  treatment  is  applicable  to  it  except  the  adoption  of 
means  to  prevent  peritonitis,  as  rest,  opiates,  leeches,  and  strict 
avoidance  of  sexual  intercourse. 

The  great  obscurity  of  the  diagnosis  of  tubal  diseases  renders 
the  subject  one  upon  which  it  is  not  profitable  to  speak  further, 
although  as  a  pathological  study  it  is  one  of  great  interest. 

Stricture. — The  Fallopian  tubes,  which  are  often  imperfect  or 
wanting  when  the  uterus  is  absent  or  undeveloped,  may,  even 
after  full  development,  be  affected  by  stricture.  The  condition 
may  be  produced  by  these  causes : 

Calcific  deposit; 
Senile  atrophy; 
Salpingitis; 
Pelvic  peritonitis ; 
Tubercle  or  fibrous  tumors. 

Partial  obliteration  of  the  canal  results  in  sterility  if  it  affect 
both  sides  simultaneously,  and  sometimes,  b}'  causing  the  accu- 
mulation of  fluids,  it  produces  tubal  dropsy.  It  is  not  rare  for 
rupture  of  the  tubes  and  consequent  hematocele  and  peritonitis  to 
result  from  imprisonment  of  menstrual  fluid  in  them.  M.  Puech 
analj'Zcd  two  hundred  and  fifty-eight  cases  of  congenital  atresia  of 
the  genital  organs,  and  found  that  in  fifteen  cases  the  Fallopian 
tubes  were  dilated,  and  in  five  were  ruptured.  The  condition  is 
rather  a  study  for  the  pathological  anatomist  than  for  the  gyneco- 
logist, for  it  can  neither  be  diagnosticated  nor  relieved  by  treatment. 

Distention. — The  tubes  may  be  distended  by  accumulation  of 
mucus,  pus,  menstrual  blood,  or  a  muco-serous  material  secreted 
by  the  altered  mucous  membrane  accompanying  great  and  pro- 
longed distention.  This  condition  invariably  has  as  its  moving 
cause,  stricture,  which  prevents  the  tube  from  emptying  itself 
into  the  uterus.  When  very  great  distention  takes  place,  the 
accumulated  fluid  either  forces  its  way  out  of  the  uterine  ex- 
tremity, constituting  the  profluent  dropsy  of  Rokitansky,  or 
passes  out  of  the  fimbriated  extremity  into  the  peritoneum,  or  a 


DISPLACEMENTS. 


769 


rupture  of  the  tube  occurs.  Such  an  accumulation  may  produce 
a  tumor  equal  in  size  to  the  head  of  a  child  of  ten  years,  and 
some  say  even  much  larger,  though  there  is  doubt  as  to  the 
authenticity  of  the  latter  cases.     Virchow  has  established  a  class 


Ficr.  191. 


Tubal  dropsy.     (Boivin  and  Duges.) 

of  cysts  which  he  styles  cysts  from  retention,  to  which  distention 
of  the  tube  by  sero-mucus  properly  belongs. 

The  diagnosis  in  advanced  cases,  where,  for  example,  the  tumor 
has  developed  to  the  extent  just  mentioned,  is  difficult  and  often 
impossil)le.  Sometimes,  however,  it  may  be  made  by  the  follow- 
ing means:  an  elongated,  fluctuating,  moval.'le  tumor  is  felt  in 
the  retro-uterine  space  a  little  to  one  side ;  in  its  outlines  the 
tumor  is  wavy,  and  it  can  be  separated  from  the  uterus.  Scanzoni 
quotes  Kiwisch  as  declaring  that,  in  such  cases,  the  presence  at 
the  side  of  the  fundus  of  a  mammillated,  elastic,  and  elongated 
tumor,  justifies  the  diagnosis  of  tubal  dropsy,  but  he  differs  from 
him,  and  regards  the  positive  diagnosis  as  impossible.  In  case 
the  diagnosis  can  be  arrived  at,  the  most  appropriate  treatment 
would  consist  in  tapping  per  vaginam. 

Displarnnenfs. — The  +ubes  may  pass  with  hernial  protrusions 
into  the  inguinal  or  crural  openings,  and,  in  case  of  inversion  of 
the  uterus,  may  descend  into  the  cavity  of  the  displaced  organ. 
It  is  generally  in  company  with  the  ovary  that  the  tube  leaves  its 
place,  but  at  times  it  descends  alone.  Dr.  Scholler'  reports  an 
instance  in  which,  in  a  child  who  died  twenty  days  after  birth,  a 


'  Courtj,  op.  cit. 


49 


770  CHLOROSIS. 

tumor  was  discovered  which  extended  from  the  inguinal  regiou 
to  the  right  labium,  and  contained  the  Fallopian  tube,  which  was 
non-adherent.  A  crural  hernia  of  the  tube  alone  which  ended 
fatally  is  likewise  recorded  by  M.  B^rard. 

Prof.  Rokitansky,'  and  Dr.  Turner,  of  Scotland,  have  both  re- 
cently drawn  attention  to  severance  of  the  tube  from  the  ovary 
by  traction  from  increased  weiglit  of  the  latter  or  from  false  mem- 
branes.    The  former  cites  twelve  instances  in  support  of  the  fact. 

Other  Diseases  of  the  Tithes. — In  addition  to  these  diseases  the 
tubes  arc  sometimes  aiFected  by  cancer,  tubercle,  fibrous  tumors. 
abscess,  and  accunmlation  of  blood  in  their  canals  from  hemor- 
rhage from  the  mucous  membrane.  There  is  so  strong  an  analogy 
between  these  disorders  and  the  same  in  other  organs,  that  it  is 
not  deemed  necessary  to  enter  upon  their  cousideration. 


CHAPTEH    XLVITI. 

CHLOROSIS. 

Definition  and  Synonyms. — This  disease  is  probably  a  neurosis  of 
the  ganglionic  system  of  nerves.  Disordering  the  control  whicli 
this  system  exerts  over  the  functions  of  organic  life,  it  produces, 
as  symptoms  of  its  existence,  impoverishment  of  the  blood,  con- 
stipation, dyspepsia,  paljutation,  and  menstrual  derangements  and 
irregularities. 

Although  it  is  probable  that  it  may  occur  in  the  male  as  well 
as  the  female ;  that  it  is  sometimes  met  with  in  women  who 
have  passed  the  age  of  puberty,  and  as  an  exceptional  occurrence 
has  been  known  to  affect  young  children,  the  ordinary  period  of 
its  invasion  is  the  time  of  puberty,  when  the  dormant  functions 
of  the  ovaries  are  being  aroused,  and  the  girl  is  rapidly  passing 
into  the  state  of  womanhood.  This  fact  has  led  many  observers 
to  suppose  that  it  is  dependent  upon  some  derangement  in  ovular 
tion  and  menstruation,  l)ut  it  is  more  probable  that  torpidity  of 
the  uterus  and  ovaries  is,  like  the  peculiar  blood  state  whicli  is  so 


Sydeahuui  Soc.  Year-Book,  1861. 


PATHOLOGY    AND    SYMPTOMS.  771 

characteristic  of  the    disorder,  merely  a    symptom  of  functional 
disease  in  the  sympathetic  system  of  nerves. 

Chlorosis  has  been  described  under  a  variety  of  names,  as,  for 
example,  Anaemia  or  Spansemia,  a  kindred  disorder  with  which 
it  has  been  commonly  confounded  by  writers ;  Chloro-ansemia, 
Green  Sickness,  Cachexia  Virginum,  Morbus  Virginius,  and  many 
others. 

Freqv.ency.— It  is  an  affection  of  great  frequency  in  all  civilized 
and  refined  communities.  The  greater  the  tendency  developed 
by  society  to  luxurious  and  enervating  habits  the  more  frequently 
is  it  encountered.  Thus  in  large  cities  and  the  higher  walks  of 
life  it  is  of  much  more  common  occurrence  than  in  country  places, 
and  among  the  lower  classes,  where  a  more  natural  and  healthy 
existence  is  passed. 

History. — -The  characteristic  feature  of  the  disorder  being 
readily  recognizable,  and  of  such  a  nature  as  to  excite  not  only 
attention  but  anxiety,  it  has,  from  the  remotest  times,  received 
some  attention  at  the  hands  of  physicians.  Although,  however, 
allusions  to  it  will  be  found  even  in  the  writings  of  Hippocrates, 
Valleix  declares  that  F.  Hoffman,'  who  wrote  in  the  middle  of 
the  eighteenth  century,  was  the  first  who  ever  gave  a  full  and 
satisfactory  description  of  it.  Sydenham,^  who  flourished  in  the 
middle  of  the  seventeenth  century,  describes  "  The  Green  Sick- 
ness," but  disposes  of  the  whole  subject,  symptomatology  and 
treatment,  in  exactly  ten  lines.  During  the  last  centuiy  the  sub- 
ject has  attracted  great  attention,  and,  thanks  to  the  investigations 
of  Andral,  Becquerel,  Rodier,  and  others,  our  knowledge  of  the 
pathology  of  the  condition  has  been  greatly  advanced. 

Pathology  and  Symptoms. — Before  approaching  this  part  of  our 
subject  special  allusion  must  be  made  to  a  fact  which  has  been 
already  mentioned,  that  chlorosis  and  anremia  are  frequently 
treated  of  as  identical  affections  under  the  latter  appellation. 
The  pathological  condition  found  to  exist  upon  chemical  analysis 
of  the  blood  in  the  two  diseases  is  often  the  same,  a  diminished 
amount  of  red  corpuscles  and  in  time  diminution  of  all  the  solid 
elements  of  the  blood.  Man}-  of  their  symptoms  are  also  the  same, 
as,  for  example,  pallor,  palpitation  of  the  lieart,  dyspnoea,  the  ex- 
!  istence  of  a  loud  systolic  cardiac  murmur,  etc.  In  spite  of  these 
facts  it  will  be  noticed  that  even  those  writers  who  treat  of  the  two 
conditions  under  the  name  of  anaemia  are  forced  to  note  the  cir- 


'  De  Morb.  Virgin.  ^  Syd.  Soc.  Ed.  of  Works,  vol.  ii,  p.  288. 


772  CHLOEOSIS. 

cumstance  that  there  is  a  peculiar  form  of  the  disease  which 
occurs  about  the  period  of  puberty,  to  females  only,  and  which 
has  characteristics  not  displayed  under  other  circumstances.  Prof. 
Flint,'  in  treating  of  the  etiology  of  anaemia,  says: 

"  The  obvious  causes  may  be  arranged  into  the  three  classes  just  stated, 
viz.:  Fi'r.sY,  causes  which  involve  an  actual  loss  of  red  globules,  as  in 
hemorrhages;  Second,  causes  involving  a  defective  suppl3'  of  material  for 
assimilation  ;  Third,  causes  which  occasion  expenditure  of  tliose  con- 
stituents of  the  liquor  sanguinis  on  which  the  production  of  red  globules 
is  dependent. 

"•  The  causes  are  not  always  apparent.  Anaemia  is  apt  to  occur  in 
females  at  or  near  tlie  age  of  pubert}',  when  there  has  been  jio  loss  of 
blood,  no  deficienc}^  in  alimentary  supplies,  and  no  unusual  expenditure 
of  blood  i)lasnia.  Under  these  circumstances  it  constitutes  the  affection 
to  which  the  name  Chlorosis  was  applied  before  the  anamic  condition  was 
fully  understood.  If  the  name  be  retained,  it  should  be  considered  as 
denoting  ana?mia  occurring  under  the  circumstances  just  stated." 

1  have  introduced  this  c^uotation  not  merely  for  the  purpose  of 
citing  the  views  of  the  eminent  author  from  whom  it  is  drawn,  but 
as  illustrative  of  the  position  of  those  who  look  upon  these  dis- 
orders as  identical  as  to  pathology,  and  differing  only  in  the  period 
of  life  at  which  they  are  developed.  As  I  proceed  with  the  de- 
scription of  the  symptoms,  course,  and  treatment  of  chlorosis,  I 
hope  to  be  able  to  justify  myself  in  following  the  example  of 
Becquerel,  Valleix^  and  many  other  French  writers,  in  looking 
upon  them  as  essentially  and  entirely  different  in  nature. 

Several  French  pathologists,  under  the  lead  of  Becquerel,  of 
Paris,  have  of  late  years  advanced  the  view  that  chlorosis  differs 
from  annemia  mainly  in  this :  that  the  latter  is  merely  a  blood 
state,  while  the  former  is  a  disease  of  the  nervous  system  which 
may  or  may  not  produce  the  latter. 

The  most  striking  differences  between  the  two  diseases  may  be 
thus  contrasted ; 

AN/EMIA.  J  CHLOROSIS. 

Ts  merely  impoverisliment  of  the  blood  Is  a  disease  of  the  iiorvons  system,  and 
due  to  war.t  of  nourishment,  from  some  !  may  occur  with  or  without  the  production 


drain  upon  the  system,  or  from  some 
poison  in  the  blood. 

Can  usually"  be  accounted  for  by  dis- 
covery of  some  special  cause. 

Occurs  at  all  periods  of  life,  to  men, 
women,  and  children. 


of  its  most  common  symptom,  aniemia. 

Cannot  usually  be  accounted  for  by 
discovery  of  special  cause. 

Occurs  in  true  type  usually  to  girls 
about  time  of  puberty. 


'  Flint's  Practice  of  Med.,  2d  ed.,  p.  62. 


PATHOLOGY  AND  SYMPTOMS. 


773 


ANyEMIA. 

Is  readily  curable  by  removal  of  cause, 
supply  of  good  diet,  and  administraliou 
of  iroa. 

Is  always  characterized  by  impoverish- 
ment of  blood. 

Produces  a  puffy  and  pale  appearance. 

Does  not  ordinarily  produce  sadness  or 
great  nervous  disquietude. 

Is  not  especially  accompanied  by  vis- 
ceral neuralgia. 

No  special  affection  of  solar  plexus  of 
nerves. 

Iron  always  does  good. 

The  cause  of  the  disease  being  re- 
moved, patient  will  rapidly  improve. 


CHLOROSIS. 

Is  affected  favorably  only  by  remedies 
which  act  upon  the  nervous  system,  as  al- 
teratives and  tonics. 

Sometimes  exists  without  impoverish- 
ment of  the  blood. 

Produces  a  light  green  color. 

Commonly  produces  sadness  and  ner- 
vous disquietude. 

Is  constantly  accompanied  by  visceral 
neuralgia. 

Pain,  uneasiness,  or  distress  commonly 
referred  to  solar  plexus. 

Iron  often  fails  to  benefit. 

If  supposed  cause  be  removed,  patient 
will  often  improve  but  slowly. 


The  rapid  development  by  which  the  girl  becomes  a  M^oman  and 
the  boy  changes  to  the  man  is  at  once  one  of  the  most  striking,  im- 
portant, and  interesting  of  the  physiological  processes  which  take 
place  in  the  animal  economy.  The  special  alterations  occurring  at 
this  time  do  not  need  enumeration  here.  All  that  it  will  be  neces- 
sary to  say  is  that  all  this  change  is  coincident  with  the  develop- 
ment of  the  ovaries  in  the  one  case  and  the  testicles  in  the  other, 
so  that  the  former  organs  become  capable  of  casting  off  matured 
ovules,  and  the  latter  of  secreting  fructifying  zoosperms.  If  any 
accident  occur  so  that  growth  and  development  do  not  take  place 
in  ovaries  or  testicles,  the  result  is  that  the  girl  never  becomes  a 
fully  developed  woman,  or  the  boy  grows  up  a  shrill-voiced,  beard- 
less, effeminate  man. 

In  the  lower  order  of  animals,  and  more  especially  in  the  males 
of  many  species,  interference  by  castration  with  development  at 
puberty,  gives  us  still  more  remarkable  results.  If  two  colts  be 
bred  in  the  same  stable  and  from  the  same  stock,  and  one  be 
castrated  and  the  other  left  entire,  the  former  will  develop  into 
the  gentle,  slender  gelding,  while  the  latter  will  grow  into  the 
strong-necked,  majestic,  and  vicious  stallion.  A  still  more  striking 
contrast  will  be  found  to  exist  between  the  ox  and  the  bull. 

This  process  of  development,  which  we  term  puberty,  is  under 
the  control  of  the  ganglionic,  or  sympathetic  system  of  nerves, 
which,  at  that  time,  must  necessarily  be  in  a  condition  of  excessive 
susceptibility.  It  is  probable  that  in  that  state  of  exaltation,  it  is, 
in  the  female,  often  affected  by  a  functional  derangement  which 
creates  the  collection  of  symptoms  to  which  we  give  the  name  of 
Chlorosis.     I  say  it  is  prol)a])k',  for  it  must  be  confessed  that  the 


774  CHLOROSIS. 

theory  which  I  have  here  stated  is  merely  an  hypothesis  suggested 
})y  clinical  observation  of  such  cases,  and  not  supported  by  post- 
mortem or  other  physical  evidence. 

To  state  this  view  in  other  words;  at  the  critical  age  of  puberty, 
when  a  series  of  important  and  peculiar  changes  are  being  eftected 
through  the  instrumentality  of  the  sympathetic  system  of  nerves, 
this  system  seems,  in  the  female,  to  be  liable  to  a  morbid  influence, 
which,  in  great  degree,  paralj'zos  it,  and  impairs  its  functions. 
Sadness,  nervousness,  and  irascibility  mark  its  onset ;  then  neu- 
ralgia develops  itself  in  the  limbs,  the  head,  and  the  viscera ;  the 
appetite  is  impaired ;  digestion  becomes  weak,  and  dyspepsia,  flatu- 
lence, and  depraved  tastes  are  encountered.  The  young  girl  craves 
the  most  unpalatable  and  innutritions  substances,  as,  for  example, 
chalk,  clay,  slate,  and  other  articles  of  alkaline  character;  while, 
at  others  times,  the  taste  prompts  her  to  consume  acids,  as  vinegar, 
lemon-juice,  pickled  vegetables,  etc.  Usually  the  process  of  blood- 
making  is  soon  disordered,  and  ansemia  sets  in,  coincidently  with 
amenorrhoca,  constipation,  palpitation  of  the  heart,  sensitiveness 
along  the  spine,  distress  in  the  solar  plexus  of  nerves,  coldness  of 
the  hands  and  feet,  and  irregular  and  excessive  flushing  of  the  face. 

Raciborski,^  from  his  allusions  to  the  aflPection  in  his  work  upon 
"  Puberty  and  the  Change  of  Life,"  evidently  regards  its  pathology 
as  due  to  disorder  affecting  the  ganglionic  nervous  system: 

"Chlorosis  is  an  affection  A'erj'  common  with  young  women  about  the 
period  of  puberty.  This  is  not  the  i)lace  for  me  to  discuss  the  primary 
nature  or  the  remote  cause  of  this  disease,  to  inquire  if  it  commences  in 
the  alteration  of  the  blood  which  characterizes  it,  or  if,  on  the  other  hand, 
as  appears  more  probable,  the  alteration  just  alluded  to  is  itself  a  con- 
sequence of  an  affection  of  an  important  part,  such,  for  example,  as  the 
great  sympathetic  nerve,  which,  by  its  numerous  relations,  would  explain 
at  the  same  time  both  this  alteration  of  the  blood  and  various  troubles 
in  the  digestive,  respiratory,  and  genital  organs,  and  all  the  disorders  of 
general  sensibility." 

Upon  pressing  along  the  spine,  a  point  of  great  sensitiveness 
v/ill  usually  be  found  near  the  seventh  cervical  vertebra,  and 
others  are  often  discovered  above  and  below  this.  Auscultation 
reveals  a  loud  basic  systolic  cardiac  murmur,  and  along  the  arteries 
the  bruit  de  souffle  can  be  detected.  It  is  not  rare  to  find  the 
sternum  and  clavicles  very  sensitive  to  pressure,  as,  likewise,  the 
intercostal  spaces. 


'  De  la  puberte,  aud  de  I'age  critique  chcz  la  femme,  p.  240. 


MODE    OF    DEVELOPMENT.  775 

Most  of  these  are  symptoms  which  mark  the  effect  of  the  disease 
upon  the  nervous  system.  The  peculiar  blood  state  usually  engen- 
dered has,  however,  received  special  attention,  and  been  hy  many 
excellent  authorities  regarded  as  the  main  element  of  the  disease. 
Becquerel,*  in  his  excellent  article  upon  this  subject,  thus  sums  u]) 
the  changes  which  are  ordinarily  effected  in  this  fluid. 

"1st.  The  water  of  the  blood  is  notably  augmented,  which 
diminishes  the  density  of  this  fluid.  The  amount  is  represented 
by  the  same  figures  as  in  anaemia. 

"  2d.  The  proportion  of  the  globules  is  diminished. 

"3d.  The  fibrin  is  usually  found  to  be  normal  in  amount. 

"4th.  The  fatty  and  saline  constituents  retain  their  normal 
proportions,  as  does  usually  the  albumen.  In  very  severe  and 
obstinate  cases,  however,  the  albumen  is  diminished,  when  we  see 
dropsical  swellings  as  a  result." 

German  pathologists  very  generally  appear  to  repudiate  the 
nervous  theory  of  the  production  of  chlorosis,  and  Rokitansky  and 
Virchow  have  advanced  the  statement  that  severe  and  incurable 
cases  are  due  to  an  aplasia,  or,  as  Virchow  would  express  it,  a 
hypoplasia  of  the  heart  and  large  arteries  and  a  defective  develop- 
ment of  the  genital  system.  According  to  them  the  disease  is  of 
congenital  rather  than  acquired  character. 

Mode  of  Development. — Chlorosis  generally  develops  itself  very 
insidiously.  In  a  girl  who  has  previously  been  in  good  health, 
languor,  sadness,  and  aversion  to  company  usually  first  attract 
attention.  These  are  followed  by  palpitation  of  the  lieart  after 
exertion,  scantiness  of  the  menstrual  flow,  and  a  characteristic 
[)ale  or  greenish  complexion.  Alarm  is  ordinarily  excited  by 
these  evidences  of  approaching  disease,  and  careful  scrutiny  soon 
discovers  others  which  have  been  already  alluded  to.  According 
to  my  observation,  the  first  suspicion  v>^hich  usually  takes  posses- 
sion of  the  minds  of  the  friends  of  the  patient,  is,  that  j.ulmonary 
consumption,  or  heart  disease,  is  about  to  develop  itself.  In  some 
cases,  an  effusion  of  serum  takes  place  into  the  areolar  tissue  of 
the  body,  into  the  pleural  cavities,  or  into  the  peritoneum,  when 
even  the  medical  adviser  is  deceived,  and  fears  that  dropsy  from 
Bright's  disease,  cardiac  disease,  or  chronic  peritonitis  is  about  to 
show  itself. 

If  an  error  in  diagnosis  lead  to  neglect  of  appropriate  treatment, 
or  if,  still  worse,  the  symptoms  of  the  disease  be  mistaken  for  thoBe 

'  Mai.  do  I'Uterus,  t.  ii.  p.  490. 


776  CHLOROSIS. 

of  plethora,  as  I  have  more  than  once  known  them  to  he,  the 
gravest  features  of  the  affection  will  sliow  themselves,  and  a  most 
critical  condition  be  established. 

Causes. — The  predisjHjsing  causes  are  well  known  to  be  sex  and 
age;  but  those  which  absolutely  excite  the  disorder  are  not  so  easily 
ascertained.  The  causes  which  are  here  recorded,  are  probably 
those  which  most  frequently  prove  active;  but  it  must  be  speciall}- 
stated  that,  in  the  majority  of  cases,  no  cause  whatever  can  be 
assigned  for  the  disease. 

Great  grief,  or  prolonged  mental  anxiety; 

Depressing  home  influences ; 

Great  fear  suddenly  excited; 

Deprivation  of  pure  air,  exercise,  and  light ; 

Disappointment  in  love ; 

Erotic  excitement  without  gratification ; 

Prolonged  watching  and  loss  of  sleep; 

Nostalgia ; 

Excessive  mental  la])or. 

The  most  marked  instances  of  the  disease  which  have  fallen 
under  my  observation,  have  occurred  under  the  influence  of  great 
grief  for  the  loss  of  a  relative,  disai)pointment  in  love,  or  home- 
sickness. Dr.  "VV.  II.  Hammond,  in  an  interesting  article  upon 
this  subject  published  in  the  I'sychological  Journal  for  July,  18GH. 
records  a  striking  instance  arising  from  sudden  and  extreme  fear. 

Before  leaving  this  part  of  the  subject,  it  is  proper  that  I  should 
state  that  Becquerol,  who  has  done  more  for  the  advancement  of 
our  knowledge  of  this  interesting  aflfection  than  any  other  modern 
authority,  admits  these  causes  with  considerable  reserve.  They 
"  can,  if  they  do  not  produce,  at  least  favor  the  development  of 
chlorosis,"  says  he  in  reference  to  most  of  those  causes  which  I 
have  recorded. 

Yarieties. — I  know  of  no  good  reason  for  dividing  chlorosis  into 
varieties.  In  one  set  of  cases,  certain  symptoms  arc  predominant; 
in  others,  a  difterent  set  of  signs  assume  the  ascendency.  It  may, 
however,  prove  useful  to  the  reader  to  lay  before  him  the  six 
forms  which  have  been  adopted  by  Becquerel.    They  are  as  follows: 

1st  form,  simple  chlorosis  ; 

2d  form,  chlorosis  with  predominance  of  cephalagia  ; 

od     "  "  "  "  dyspnoea  and  palpitation ; 

4th   "  "  "  "  gastralgia; 

oth  "  "  "  "  menstrual  disorder; 

6th  "  "  "  "  general  feebleness. 


TREATMENT.  777 

Differentiation. — An  aggravated  case  of  this  disease  may  be  con- 
founded witli  ansemia,  cardiac  disease,  tubercular  pleuritis  or  peri- 
tonitis, or  even  with  the  first  stage  of  tubercular  phthisis.  From 
all  these  a  careful  and  intelligent  search  for  the  evidences  of 
organic  lesions  will  usually  distinguish  it  in  time ;  but  without 
watching  the  progress  of  the  case  for  a  considerable  period,  it  is 
often  impossible  to  decide  as  to  the  diagnosis. 

The  physician  is  frequently  deterred  from  arriviiig  at  a  positive 
conclusion  as  to  the  existence  of  chlorosis,  by  imagining  that  the 
disorder  is  identical  with  antemia.  Drawing  from  the  veins  of  the 
patient  a  drop  of  blood,  he  puts  it  under  the  microsco[ie,  and  to 
his  surprise  finds  it  to  contain  red  globules  in  normal  amount,  and 
concludes  that  his  suspicions  were  incorrect.  It  is  a  well-known 
fact  that  the  disease  may  exist  in  aggravated  form  with  little  or 
no  blood  change. 

Complications. — Chlorosis  may  be  complicated  by  hysteria,  hypo- 
chondriasis, hypertrophy  of  the  heart,  and  tuberculosis.  In  one 
case  which  I  have  seen,  chlorosis  developed  itself  with  most 
unmistakable  symptoms,  and  then  violent  chorea  showed  itself, 
which  proved  fatal  after  lasting  about  two  years. 

Prognosis. — Unless  some  serious  disorder  complicate  it,  the  prog- 
nosis is  always  good ;  but  the  course  and  duration  of  the  disease 
cannot  be  predicted.  If  all  the  surroundings  of  the  patient,  l)oth 
social  and  physical,  be  altered,  and  all  causative  influences  removed, 
recovery  may  be  rapid  and  complete ;  but  if  these  circumstances 
cannot  be  brought  about,  the  aliection  may  last  for  an  indefinite 
time. 

Treatment. — Treatment  should  consist,  not  in  fruitless  attempts 
to  overcome  one  or  even  two  of  the  results  of  the  disease,  amenor- 
rhoea  and  anaemia,  for  example,  but  in  a  systematic  effort  to  accom- 
plish these  three  ends : 

1st.  To  remove  the  cause  of  the  disorder ; 

2d.  To  cure  the  neurosis  itself; 

3d.  To  repair  the  damage  which  it  has  efifected  in  the  system. 

If  any  of  the  causes  which  have  been  enumerated  be  found  to 
exist,  it  should  as  far  as  possible  be  promptly  and  entirely  removed. 
In  many  cases  the  cause  cannot  be  discovered,  and  in  many,  it 
discovered,  cannot  be  removed ;  but  if  search  be  always  made  for 
it,  a  sufficient  number  of  successes  will  occur  to  reward  the  efibrt. 

Even  where  the  special  cause  cannot  be  detected,  recovery  may 
be  accomplished  by  removing  the  patient  from  home,  and  send- 


'H 


778  CHLOROSIS. 


ing  her  to  a  distance  from  objects  and  people  connected  with  the 
sadness  and  depression  attendant  upon  the  inception  of  the  attack. 
A  visit  to  some  agreeable  watering-place  or  lively  country  resort, 
if  the  patient  live  in  a  city,  or  to  some  large  and  busy  city,  if  she  ,.^ 
resides  in  the  country,  will  often  do  more  in  the  way  of  cure  than 
can  be  eflected  by  any  amount  or  kind  of  medication.  A  sea- 
voj^age  and  visit  to  a  foreign  country  Avill  often  produce  a  most 
excellent  result,  and  sometimes  cause  complete  cure. 

Well-regulated  exercise  in  the  open  air  is  of  great  importance. 
Horseback  exercise,  rowing,  bowling,  walking,  playing  at  tenpins, 
etc.,  constitute  some  of  our  best  nervous  tonics.  Sea-bathing,  and 
more  particularly  surf-bathing,  is  very  useful,  and  should,  when 
attainable,  l^e  faithfully  tried.  All  of  these  are,  however,  inferior 
in  value  to  cheerful,  and  congenial,  society.  This  accomplishes  a 
change  in  the  nervous  system  wdiich  nothing  else  so  surely  effects. 

In  the  moan  time,  nervous  tonics  should  be  freely  given.  The 
best  of  these  are  the  preparations  of  arsenic,  strychnine,  and 
quinine.  Should  the  patient  bear  it  well,  the  continuous  electric 
current  should  be  employed,  and  general  electrization  often  ])roves 
very  beneficial. 

As  anaemia  is  usually  a  complication  of  the  disease,  iron  is 
generally  indicated.  Some  of  the  best  preparations  are,  the  sac- 
charated  carbonate,  iron  by  hj'drogen,  and  the  bitter  wine  of  iron. 
A  very  excellent  combination  is  offered  by  the  following  prescrip- 
tion : 

R. — Forri  vini  amari,  Jvijss; 
Tr.  nucis  vomiciE,  ^iv  ; 
Solut.  potassa;  arsen.  ,^ij. — M. 
S. — A  dessertspoonful,  in  a  claret-glassful  of  water  just  after  each  meal. 

The  diet  should  be  extremely  nutritious,  consisting  of  meat, 
milk,  animal  broths,  eggs,  and  vegetables,  with  wine,  whiskey,  or 
malt  liquors,  if  these  apjiear  necessary  on  account  of  great  exhaus- 
tion. 

Should  the  pathology  of  severe  cases  be,  as  suggested  by  some  of 
the  most  eminent  German  pathologists,  an  undevelojjed  state  of 
some  of  the  important  organs  of  the  body,  of  course  nothing  will 
result  from  treatment  except  palliation  by  improvement  of  the 
existing  blood  and  nerve  states. 


INDEX. 


ABDOMEN,  applications  to  the,  in  peri- 
tonitis, jit'ter  ovariotimij-,  7G2 
Abdominal  ovariotomy,  738 

palpation,  conjoined  with  the  use  of 
the  sound,  (>3 
in  physical  cxaininaTion,  63 
supporter  after  ovariotomy,  763 

in  anteversion,  366 
viscera,  tlistenti..n    of,  diflferentiation 
from  ovarian  tnmor,  689 
A.blation  of  uterus,  519 
dantjers  of,  521 
statistics  of,  520 
Abnormal  growths,  a  cause  of  sterility, '627 
Abortion,  inductiini  of,  as  a  cause  of  ute- 
rine disease,  51 
Abscess    and   cyst   of   the   vnlvo-vaginal 
glands,  93 
pelvic,  481 

causes,  482 
course,  482 
definitifui,  481 
ditferentiatioii,  483 
duration,  482 

evacuation,  best  point  for,  486 
methods  of  operating  ui)on,  486 
pathology,  481 
physical  signs,  482 
prognosis,  484 
puncture  i)er  vaginam,  485 
routes  for  discharge  of,  483 
sac,  means  of  closure  of,  487 
symptoms,  482 
terminatiun,  482 
treatment,  484 
AiMie  of  the  vulva,  96 
Ailenoma  of  the  ovary,  664 
Air  pessary  of  Gariel^  176,  272 
Amenorrhoen,  610 
Vjaths  in,  617 
causes,  612 
definition,  610 
differentiation,  613 
frequency,  610 
menopause  a  cause  for,  613 
pathology,  611 
tardy  menstruation,  614 
treatment,  614 
local,  615 

cupping  in,  616 
enemata,  stimulating,  617 
electrii'ity,  616 
sounds,  ()16 
teuts,  616 


Amenorrhoea,  varieties,  611 
Am]mtation  of  cervix  uteri,  629. 

conditions  demanding,  630 
dangers,  630 
history,  629 

operations  by  bistoury,  63. 
ecraseur,  631 
galvano-caustic,  632 
methods  of  performance, 

631 ; 
scissors,  631 
varieties  of,  631 
of  uterus  forinversi(ui,  methods  of,  4.51 
objections  to,  45!) 
Anaemia  distinguished  from  chlorosis,  772 
Anaesthesia  in  physical  (li;ignosis,  60 
Anatomy  of  the  vulva,  86 
Angioma,  urethral  venous,  119 
Anteflexion  of  the  uterus,  axes  of  uterus 
in  different  flexions,  403 
definition,  402 
irreducible  flexions,  408 

operation  lor,  412 
pessary  for,  neck   forward,  body 
normal,  407 
Hnrd's,  407,  408 
physical  signs,  404 
posterior  section  of  cervix  in,  413 
prognosis,  404 
reducible  flexions,  bod.v  forward, 

etc.,  405 
scissors  for  slitting  cervix,  414 
symi)toms,  403 
treatihent,  405 

by  intra-uterine  stems,  409, 411 
varieties,  402 
Anteversion    of    the    uterus,    .abdominal 
jiressure,  removal  of,  365 
sujiportci',  366 
course,  .361 
definition,  357 
diagnosis,  362 
ditterentiation,  .363 
dorsal  decubitus  in,  .365 
duration,  361 
frequency,  3.57 

means  of  retaining  uterus  in  posi- 
tion, 365 
normal  position  of  uterus,  359 
pess.aries,  366 
Cutter's,  370 
Hewitt's,  371 
Hitchcock's,  .369 
maxims  for  using,  .371 

( 779  ) 


780 


I X  D  E  X . 


Anteversion  of  the  iiterns — 

pessaries,  Tliuinas's,  3(38,  369 
pretlisiiosiiif;  causes,  3G0 
prognosis,  363 
reduction  of,  means  for,  ^64 
statistics,  358 
s.yinpton)s,  361 
termination,  361 

treatment    of    anterior    displace- 
ments   in    which    version     pre- 
dominates over  tiexions,  363 
urine,  jirolouged  retention  of,  in, 

365 
varieties,  362 
Apoplexy  of  the  ovary,  642 
Apparatus,  Bozetiian's,   for  secnritig   pa- 
tient during  operation  for  vesico-vaginal 
fistula,  etc.,  734 
Areolar  hyperiiLisia  of  the  uterus,  274 
Andral  on,  276 
Snow  Beck  on,  283 
J    H.  Bennett  on,  275,  276 
causes  for,  2!)2,  293 
cervical,    physical     signs    of, 

294 
comi)lications,  297 
consequent  ujion  non-puerpe- 
ral causes,  288 
corjioreal,   physical    signs    of, 

294 
counter-irritation  in,  306 
course,  289 

cupping  cervix  uteri  for,  304 
definition,  274 
depletion  in,  302 
differentiation,  295,  296 
Finn  on,  280 
frequencv,  291 
Gaillardon,  285 
Grailv  Hewitt  on,  277 
Hodge  on,  278 

indications  for  treatment,  300 
Kiwiscli  on,  278 
Kloh  on,  277.  278 
Lisfranc  on,  278 
local  alteratives  in,  306 
mineral  waters  in,  301 
nomenclature,  274 
pathology,  281 
predisposing  causes,  292 
prognosis,  296 
removal    of  cervix    uteri  for, 

308 
rest  in  treatment  of,  300 
resunu'  of  article  on  i)athologv 

.if,  289 
Scauzoni  on,  278 
Simpson  on,  282 
stages  of  the  disease,  288 
subinvolution,  a  cause  of,  285 
symjitoms,  293 
tenriination,  289 
treatment  of,  297 

general,  301 
vaginal  injections  for,  304 
varieties,  290 
West  on,  28.!,  290 
Ascent  of  the  uterus,  327 
Ascites,     dirt"ereiitiation      from      ovarian 

dropsy.  690 
Aspiration  in  diagnosis  of  ovarian  tumor, 
698 


Aspirator  as  a  means  of  physical  diagno- 
sis, 83 
Dieulafoy's,  84 
Atresia  vaginse,  161 

Amussat's  operation,  166 

causes,  162 

ileflnition,  161 

ditt'erentintion,  163 

Dupiivtien's  operation,  166 

history,  161 

methods  for  evacunting  retained 

menstrual  hlood,  165 
operation  to  render  an  ohliterated 
vagina  jiervions,  166 
Dupiiytren's,  166 
pathology,  161 
physical  signs,  163 
prognosis,  163 
results,  163 
symptoms,  162 
synonyms,  Kil 
treatment,  1()4 
varieties,  Kil 
Atrophy  of  the  ovary,  641 
Auscultation,  as  a  means  of  physical  diag- 
nosis, 85 
Aveling's  polyptome,  614 


T^ATHS  in  amenorrhoea,  617 

Iv         in  lli(^  treatment  of  areolar  hyjier- 

])l;isia  of  the  uterus,  301 
Bimanual  palpation  in  jihvsieal  diagnosis, 

62 
Bladder,  extensive  destruction  of  the  base 

of,  in  fistuhe,  210 
Blind  vaginal  fisiulie,  215 
Blistering  the  cervix  uteri  in  areolar  hy- 

jierjilasia  of  the  uterus,  306 
Blood,    retained   menstrual,    methods    of 
evacuating,  165 
treatment  of,  168 
Bozeman's  app;iratus  for  securing  jiatient 
during  operation  lor  vesico-vaginal  fis- 
tula, etc.,  734 
Broad  ligament,  c.ysts  of,  677 
Bulbs  of  the  vestibule,  anatomy  of,  97 
rupture  of,  97 


pANCEE  of  the  body  of  the  uterus,  dif- 
V,,'  feren  tint  ion,  565 

peculiar  features,  564 
of  the  ovary,  653 
of  the  uterus,  543 

causes,  exciting,  559 
predisjiosing,  557 
caustics  in,  568,  570 
complications,  563 
constitutional  treatment,  572 
definition,  543 
differentiation,  561 

of  cancer  nf  the  bmlj-,  565 
encephaloid,  546 
epithelioma,  546-549 

vegetating,  554,  557 
frequency,  547 

relative,  of  different  varietie.s, 
647 
galvano-cantery  in,  567 
gas-jet  cautery,  570 
history,  544 


INDEX, 


781 


Cancer  of  the  nferns — 

maliyiiaiit  iiapilloma,  555,  556 

o|iiiiiM  ill,  571 

parts  of  uterus  aflfected,  563 

pathology,  544 

peculiar  features  of  cancer  of  the 

l.ody,  564 
physical  sifxus,  560 
]irogiiosis,  562 
scirrhus,  546,  549 
Siinon's  scoop  ju,  569 
statistics,  547,  558 
table    of    organs    secondarily    af- 
fected, 549 
tables,  553,  557,  562,  568 
treatiiK'ut,  56() 

resuuic  oC,  573 
Cancroid  and  cancerous  afiections  not  to 

be  separated,  546 
Carcinoma  of  ovary,  652,  653 

of  the  uterus,  548 
Caruncle,  irritable  urethral,  116 
causes,  117 
course,  118 
differentiation,  118 
duration,  1 18 
pathology,  IIC) 
physical  sijjns,  117 
prognosis,  lis 
treatment,  ]  18 
Catheter,  Sims's  sigmoid,  198 
Cautery,  galvaiu)-,  632 
Byrne's,  (i32 

cancer,  remoA-al  of,  by,  667 
cervix  uteri,  removal  of,  bj^,  633 
polypi,  removal  of,  by,  638 
gas-jet,  570 
Cellulitis,  ])ei-iuteriiie,  452 
anatomy,  452 
causes,  458 
compiicJitions,  456 
couseiiueiices,  462 
course,  457 
definition,  453 
dift'erentiation,  462,  476 
duration,  457 
frequency,  453 
history,  452 
pathology,  454 
physical  signs,  460 
post-mortem    records,    tables    of, 

465 
prognosis,  458 
syniiitfuns,  459 
synonyms,  453 
termiiKitioii,  457 
treatment,  462 
Cervical  constriction,  dilatation  of,  589 
endometritis,  chronic,  236 

ablation    of    diseased   glands, 

251 
alterative  ap])licntions,  246 
anatomy  of  cervical    mucous 

membrane,  237 
onuses,  exciting,  240 
predisposing,  239 
course,  243 

curette,  Sims's,  in,  252 
definition,  236 
destruction  of  diseased  glands, 

251 
duration,  243 


Cervical  endometritis,  chronic — 

emollient  ai)])lications,  245 
frequency,  'S.il 
general  regimen,  244 
pathology,  238 
physical  signs,  242 
prognosis,  243 
symptoms,  241 
synonyms,  237 
termination,  243 
treatuient,  244 
Cervix  uteri,  amputation  of,  629 

conditions  demanding,  630 
dangers,  630 
history,  629 

operation  by  bistotiry,  631 
by  ccraseur,  631 
by  gah'ano-caustic,  ()32 
by  scissors,  (531 
methods  of  ])erformai^.ce, 

631 
varieties,  631 
conoidal,  a  cause  oi  sterility,  626 
cystic  degeneration  of,  309 
causes,  317 
definition,  316 
pathology,  316 
prognosis,  317 
synonyms,  317 
treatment,  317 
double  scissors  for  slitting,  414 
dry  cupinng,  syringe  for,  616 
granular  degeneration  of,  309 

alterative       applications, 

314 
causes,  exciting,  310 
predisposing,  310 
cock's-comb  granulations, 

314 
congestion,  prevention  of, 

315 
course,  311 
definition,  309 
duration,  311 
frequencv,  309 
pathology,  312 
physical  signs.  311 
prognosis,  312 
sym])toms,  311 
treatment,  313 
incision  of,  for  dysmenorrhcea.  59') 
instruments  for,  590,  591, 

592 
Sims's  method,  591 
cedematous  eloi  gatiou  of  and  pro. 

lajise  of,  337 
posterior  section  of,  in  Hexions,  4i;> 
prolapse  of,  337 

removal  of,  for  areolar  by  jierplasia, 
by  galvano-cautery,  308 
by  scissors,  308 
ulcer,  syphilitic,  of,  318 
course,  319 
differentiation,  319 
fre<iuency,  318 
termination,  319 
treatment,  320 
Chlorosis,  770 

blood  state  in,  775 
causes,  776 
com j)licat ions,  777 
definition,  770 


782 


INDEX. 


Chlorosis — 

development,  mode  of,  775 

different i;il  diagnosis,  772,  777 

etiology,  Flint  on,  772 

frequency,  771 

history,  771 

pathology,  771 

prognosis,  777 

synVpathetic    nervons    system,    func- 
tional derangeiiieuL  of,  773,  774 

symptoms,  771 

synonyms,  770 

treatment,  777 

varieties,  776 
Chorion,  cystic  degeneration  of,  576.    (See 

Hydatids,  ittekinb.) 
Chronic  corjioreal  endometritis,  254.    (See 

CORPOKKAL      ENDOMETRITIS,      CHRO- 
NIC.) 

Clamp,  Daw-son's  permanent,  after  ovari- 
otomy, 750 
temporary,     during     ovariotomy, 
7-18 
French,  used  in  ovariotomy,  750 
Spencer  Wells's,  for  securing  the  pedi- 
cle after  ovariotonty,  749 
Thomas's  tootlied-,  used  in  operation 

for  narrowing  the  vagina,  355 
time  of  removal  of,  after  ovariotomy, 
7(53 
Clamp-shield,  Storer's,  752 
Clitoris,  anatomy  of,  ,«6 
Closure  of  the  vagina  for  fistula,  207 
Coccyodynia,  120 
anatomy,  122 

case  described  by  Dr.  Nott,  120 
causes,  122 
definition,  120 
differentiation,  123 
frequency,  120 
history,  120 
pathology,  122 
prognosis,  123 
symptoms,  123 
treatment,  123 
Coccyx,  extirpation  of,  for  neuralgia,  120 
t'ock's-conib    granulation    of    the    ctirvix 

uteri,  314 
Colloid  degeneration  of  the  ovary,  652,  660 
Conce]>tio!i,    i)revention    of,    a    cause    of 

uterine  disease,  51 
Congestion  of  cer\ix  uteri,  prevention  of, 

315 
Congestive    or    inflammatory   dysmenor- 
rhcea,  584 
causes,  585 
definition,  584 
differentiation,  585 
prognosis,  ."St; 
symptoms,  5S5 
treatment,  ."iSfi 
Conjoined  manipulation  in  physical  diag- 
nosis, 62 
Conoidal  cervix,  a  cause  of  sterility,  626 
Cori^oreal  endometritis,  chronic,  254 
alteratives  in,  263,  265 

solid,    application    of,    to 
endometrium,  266 
anatomy,  255 
causes,  exciting,  2'ii^ 
predis|iosing,  i:,">7 
complications,  L63 


Corporeal  endometritis,  chronic — 
course,  1:63 
curette  in,  1:73 
duration,  263 
frequency,  254 

injections  into  uterine  cavity, 
266 
dangers  of,  267 
medicated,  into  the  uter- 
ine cavity,  271,  272 
ointment  sj'ringe,  Lente's,  2()5 
ointments,  use  of,  in,  265 
pathology,  256 
physical  signs,  2()2 
prognosis,  257 

favorable  or  unfavorable, 
257 
scarification,  intra-uterine,  in, 

274 
symptoms,  260 
synonyms,  254 
terminatii  n,  263 
treatment,  263 
Corroding  ulcer  of  the  uterus,  552 
(■ounter-irritation  in  areolar  livperplasia, 

306 
Cupping  cervix  uteri  in  amenorrha'a,  616 

instruments  for,  304 
Curette,  copi)er  wire,  in  tieattnent  of  fun- 
gous degeneration  of  uterine  mucous 
membrane,  273,  60!t 
steel,  Sims's,  for  removal  of  diseased 
Nabothian  glands,  252 
Cylinder,  hard  rubber,  for  cupping  cervix 

uteri,  304 
Cvst  and  abscess  of  vulvo-vaginal  glands, 

93 
Cyst,   fibro-,   uterine,  dift'erentiated  from 

ovarian  cyst,  693 
Cystic  degeneration  of  the  cervix  uteri, 
309.    (Sec  Cervix  UTERI,  CYS- 
TIC de(;fneration  of.) 
of  the  chorion,  576.     (See  HYDA- 
TIDS, UTERINE.) 
diseases  of  the  abdomen,  differential 
tliagnosis  from  ovarian  dropsy,  692 
Cystocele,  173 
Cysto-fibroma  of  ovary,  657 
Cysto-fibromata  of  uterus.  523.     (See  Tx^- 

MORS,  PIBRO-CYSTIC.) 

Cysto-sarcoma  of  the  ovary,  657 
Cysts  and    cystomata  of  the   ovary,   662. 
(See    Tumors,  Ovarian   cysts, 
and  Cystomata.) 
dermoid,  of  the  ovary,  658 
of  the  broad  ligament,  677 
ovarian,  662 

a<lenoma  of,  664 

age  of  occurrence.  673 

aspiration  in,  698 

causes,  673 

conditions    likely   to  complicate, 

677 
contents  of,  666 

chemical  constituenrs  of,  667 
cure,  sjiontaneous,  of,  ()75 
death,    methods    by    which,    pro- 
duced, 677 
dermoid,  658 

age  of  occurrence,  659 
case  of,  659 
diagnosis,  682,  688 


INDEX. 


7S3 


Oysts,  ovarian,  diagnosis — 

conditions    likely    to   mislead 

in,  G87 
crucial  tests  in,  C08 
existence  of  a  tumor,  683 
"is  llie  tumor  ovarian  ?"  684 
rules  for   avoiding   errors  in, 

701 
abdominal  viscera,  distention 
of,  689 
walls,  abnormal  thickness 
or  tension  of,  688 
amnion,  dropsy  of,  695 
ascites,  690 
cystic   disease  in  otlier  parts 

of  the  abdomen,  692 
diseased  states  of  pelvic  walls 

and  areolar  tissue,  696 
dropsy,  tuljal,  679 
tliiid      peritoneal     accumula- 
tions, 690 
hydatids,  678 
pregnancy,  694 
spinal  cord,  cysts  of,  681 
subjieritoneal  cysts,  680 
Tiscera,     excessive     develop- 
ment of,  or  displacement  of, 
694 
diseased  conditions  affecting,  675 
explorative  incision  in,  700 
"granular  cell"  of  Di'ysdale,  671 
history,  natural,  of,  674 
metalliiimen,  test  for,  668 
microscopical  appearance  of  fluid 

contained  in,  669 
monocysts,  665 
multilocular,  664 
paralbuinen,  tests  for,  667 
parasitic,  678 
])athology,  663 
paucilocnlar,  665 
])edicle,  length  of,  697 
physic;il    exploration,    means    of, 
685 
signs,  683 
removal  of,  717.     (See  Ovakiot- 

OMY.) 

symiitoms,  681 

tapiiiiig,  700,  702 

treatment,  701 

varieties,  664 
parasitic  or  hydatid,  678 
spinal  cord,  connected  with,  681 
subperitoneal,  680 


DEGENERATTOISr,  granular  and  cystic, 
of  the  cervix  uteri,  309.   (SeeCEiiv  ix 

TJTEKI,     GKANULAK     AND     CY.STIC, 
ETC.  ETC.) 

Dr'pressor,  Situs's  vaginal,  69 

Dermoid  cyst  of  the  ovary,  658 

Descent  of  the   uterus,   328.      (See   Pko- 

I>APSUS  OF  THE  UTEKUS.) 

DiMgnosRs  of  diseases  of  the  female  genital 
organs,  54 
means  of  making,  55 
rational  signs  used  in,  67 
of  ovarian  tnmors,  rules  for  avoiding 

errors  in,  701 
physical,  means  of,  60 

abdominal  palpation,  63 


Diagnosis,  physical,  means  of— 

abdominal  palpatir)n  conjoined 
with  the  use  of  the  sound,  63 
anaesthesia  in,  60 
aspirator,  83 
auscultation.  So 
bimanual  jialjiation,  62 
conjoined  manipulation,  62 
exploring  needle,  83 
inspection,  64 
microscope,  84 
percussion,  85 
probe,  75 

recai)itulatif)n  of,  85 
rectal  touch,  64 
Simon's  niclliud,  65 
sound  in,  73 
specula,  va'ieties  of,  68 
speculum,  ()6 
sponge  tents,  77 
tents,  ("7 

vaginal  touch,  60 
vesico-rectal  exjiloration,  66 
Dilating  forceps  for  sejjarating  vagina  and 

bladder,  354 
Dilator,   JNIolesworth's  cervical,  in   treat- 
ment of  uterine  fibroids,  513 
Priestley's,  for  contracted  cervix  uteri, 

590 
Sims's  vaginal,  145 
used  in  inverted  nterns,  449 
Diseases  of  Fallopian  tubes,  7()4,  770 

of  the  ovaries,  6.34.     (See  OVAR1E.S, 

DISEASE.S  OF.) 

resulting  from    retention   and   altera- 
tion of  the  fcetal  envelojies, 
574 
hydatids,  uterine,  576 
moles,  uterine,  574 
of  the  vulva,  86 
eruptive,  95 
uterine,  considerations,  general,  upon, 
216 
diagnosis,    imperfect,    in, 

224 
factors,  especial,  in,  218 
gener.al  nianagcinent  and 
hvgiene  in,  inattention 
to,  226 
prognosis  in,  222 

erroneous,  in,  225 
therapeutics,  inefVic'i'Mt  or 

inappropriate,  22.") 
treatment,     rc.-ison.s      for 
failure  in,  224 
Displacements  of  the  Fallo])ian  tubes,  769 
of  the  ovaries,  643 
of  the  uterus,  320 

en  uses,  general,  325,  .326 
CM  rising  dysineniirrha'.i,  587 
definition,  323 
general  considerations,  320 

propositions  alioiil,  322  • 
history,  .';20 

pathological  significance  of,  .322 
synonyms  of,  323 
varieties,  325 

Graily  Hewitt  on,  .34 
Distention  of  the  F;illo))ian  tubes,  76.-!,  767 

cases  of,  7<)7 
Drainage  after  ovariotomy,  establisUmeut 
of,  755 


784 


INDEX. 


Drainage — 

of  ovarian  tumors,  Kiwisch's  meibod, 
709 
Not'ggerath's  nietliod,  709 
)>i'r  vaginain,  755 
Sclinettei-'s  method,  709 
West's  niethod,  710 
tultp,  glass,  Thomas's,  756 
Dress,  im])rc)prietits  in,  a  cause  of  uterine 

disease,  46 
Drojisy,     ovarian,     difi"erenti:itiun      from 
ascites,  6'JO 
tnhal,  679 
DysnienorrlicEa,  o'9 

congestive  or  nillanimatory,  58-i 
causes,  5X5 
definition,  584 
differentiation,  585 
proguosis,  586 
symptoms,  5X5 
treatment,  5X0 
mem hra nous,  593 
definition,  593 
dirterentiation,  596 
etiology,  594 
frequency.  5'.M) 
nieinhrane  in.  '97 
pathology,  593 
prognosis,  597 
sterility  caused  iiy,  626 
symptoms,  596 
treatment,  598 
neuralgic,  5X2 
causes,  582 
ditt'erentiatiou,  583 
ju'ognosis,  5X3 
symptotus,  5X2 
treatment,  5X3 
obstructive,  586 
causes,  5X7 
ditterenliation,  588 
l>athoU)gy,  5X7 
progiuisis,  5H8 
symptoms,  588 

treatment  of  cervical  constriction, 
589 
hy  dilatation,  r>H9 
by  expanding  instru- 

"meiits,  589 
by  imising  the  cervix, 
590 
hysterotome.Simjv 
son's  590 
Stohluiann's, 

591 
White's,  592 
Sims's  metln>d  of, 
.^90 
bv  Priestley's  dilator, 

'590 
by  tents,  589 
when   caused  by  dis- 
])lacemeuts,  592 
polypus,  593 
of  vaginal  stricture,  693 
of  fibroids,  593 
of  obturator  hymen,  593 
ovarian,  600 

definition,  600 
pathology,  601 
]irognosis.  601 
symptoms,  600 


Dysmenorrhoea,  ovarian — 
treatment,  601 

pathology,  5X0 

seat  of  pain,  581 

varieties,  581 
Dysmenorrhoeal  membrane,  597 


Ij^CRASEMENT  in  treatment  of  uterine 
J  fibroids,  514 

polypi,  537 
Ecraseur,  amputation  of  cervix  uteri  by,  631 
Chassaignac's,  515 
in  treatment  of  uterine  tumor,  515 
wire  roi)e,  Braxton  Hicks's,  515,  537 
Eczenui  of  vulva,  95 
ICIastic    jiressure    in     reducing     inverted 

uterus,  4.36 
Electricity  in  amenorrhcea,  61(5 

in  imperfect  development   of  ovaries, 
640 
Elephantiasis  of  the  vulva,  95 
Elytroplastv,  206 
Elytrorrhapby,  ^r>0 

Emmet's  operation,  .352 
Sims's  operation,  351 
Thomas's  operation,  354 
Enceiihaloid  cancer,  646,  549 
Endometritis,  a  cause  of  sterility,  626 
acute,  229 

causes,  230 
com plii'ai ions,  233 
diftVrentiation,  232 
duration,  2.34 
freiiuency,  229 
patliology,  232 
physical  signs,  231 
)>rognosis,  235 
Scnnzoni  on,  2.32 
symjitoms,  231 
pynouyms,  229 
termination,  2.34 
treatment,  235 
vari.-ties,  229 
cervical,  chronic,  2.36 

ablation  of  diseased  glands,  251 
alterative  ajtplications,  246 
anatomy  of  cervical    mucous 

memVirane,  237 
causes,  exciting,  240 
predisposing,  239 
course,  24.3 
curette,  Sims's,  252 
definition,  236 
destruction  of  diseased  glands, 

251 
duration,  243 

enu)llieni  apy>lications,  245 
freiiuency,  237 
general  regimen,  244 
pathology,  238 
physical  signs,  242 
prognosis,  243 
symptoms,  241 
synonyms,  2.37 
termination,  243 
treatment,  244 
corporeal,  chronic,  254 

alteratives  in,  263,  265 

solid,    ajiplieation    of,    to 
enilometrinm,  206 
anatomy,  255 


INDEX, 


785 


Endometritis,  corporeal,  chronic — 
causes,  exciting,  258 
predisposing,  257 
complications,  263 
course,  263 
curette  in,  273 
duration,  26:> 
frequency,  254 

injections  into  uterine  cavity, 
267 
dangers  of,  267 
medicated,  1:71,  272 
rules  for,  272 
ointment  syringe,  Lente's,  265 
ointments,  use  of,  iu,  265 
pathology,  256 
physical  signs,  262 
prognosis,  257 

favorable  or  unfavorable, 
257 
scarification,  intra-uterine,  in, 

274 
symptoms,  260 
synonyms,  254 
terniinatiun,  263 
treatment,  263 
Endometrium,  application  of  solid  altera- 
tives to,  266 
Enemata,  stimulating,  in  amenorrhcea,  617 
Euterocele,  175 
Entero-vaginal  fistul.'E,  215 
Enucleation  of  uterine  tibroid  tumors,  516 

of  ovarian  tumors,  744 
EjiisiDrrhaphy,  177,  357 
Epithelioma  uteri,  546,  549 
tables,  553 
ulcerating,  -552 
A'egetating,  554 
Ergot,    subcutaneous     injections     of,     in 
fibroid  tumors  of  uterus,  Hiluebraudt's 
cases  of,  511 
Eruptive  diseases  of  the  vulva,  95 
Erysipelas  of  the  vulva,  96 
Erythema  of  the  vulva,  96 
Etiology  of  uterine  diseases,  43 

excessive  development  of  the 

nervous  system,  45 
imi^roprieties  of  dress,  46 

during  menstruation,  48 
imiirudeuce  after  parturition, 

49 
induction  of  abortion,  51 
marringe  with  existing  uterine 

disease,  52 
prevention  of  conception,  51 
want  of  air  nnd  exercise,  44 
Examination,  physical,  59 

management  of  patient  during,  59 
Simon's  method  of,  65 
Excessive  development  of  nervous  system 

a  cause  of  uterine  disease,  45 
Excision  of  uterine  fibniid  tumors,  514 
Explorative  incision  in  diagnosis  of  ova- 
rian tumors,  700 
Exploring  needle  as  a  means  of  physical 
diagnosis,  83 
the  pelvic  viscera,   recapitulation  of 
means  for,  85 


II^ALLING  of  the  womb,  328     (See  Pro- 
lapsus OF  THE  UTERUS.) 

50 


Fallopian  tubes,  764 

anatomy,  764 

diseases  of,  764,  770 

displacements,  769 

distention  of,  766,  768 
cases  of,  767 

inflammation  of,  766 

salpingitis,  766 

stricture  of,  768 
causes  of,  768 

tubal  dropsy,  7()9 
Fasciculated  cancer.  539.     (See  SARCOMA 

OF  THE  UTERUS.) 

Fecal  fistula;,  212 
causes,  212 
definition,  212 
physical  signs,  213 
prognosis,  213 
symi)toms,  213 
treatment,  214 
A^arieties,  178,  212 
impaction,  differentiation  from  pelvic 
peritonitis,  477 
Fibro-cystic    luniurs   of   the    uterus,    523. 
(See      Tumors,     fibro-cystic,     of 

UTERUS.) 

Fibroids,    uterine,    499.      (See    Tumors, 

FIBROID,  of  uterus.) 
ditiereutial  duignosis  troui  partial 
inversion  of  the  uterus,  430 
Fibroma  of  the  ovary,'  655 
Fibrous  tumor  of  the  ovary,  655 

of  the  uterus,  diff'erential  diagno- 
sis from  pelvic  hematocele,  49ii 
Fistula,  bladder,  with  extensive  destruc- 
tion of  the  base  of  the,  210 
entero-vaginal,  215 
fecal,  212 

causes,  212 
defiuiiion,  212 
phy.sical  signs,  213 
prognosis,  213 
symptoms,  213 
treatment,  214 
varieties,  178,  212 
of  female  geuitnl  organs,  178 
definition,  178 
varieties,  178 
uretero-uterine,  211 
urethro-vagiual,  179 
urinarv,  178 

causes,  180,  181,  183 

requiring  special  treatment,  209 

symptoms,  183 

varieties,  178 
A'esico-utero-vaginal,  179,  210 
A"esico-uterine,  171,  209 
A'aginal,  siuii)le,  178,  215 
blind  vagimil,  215 
definition,  215 
peritoneo-vaginal,  215 
vesico-vaginal,   Bozcmati's  apjiaratun 
used  in,  7.34 
catheter,  sigmoid,  Sims's,  198 
causes,  180,  181,  183 
cauterization,  191 
complications,  184 
closure  of  vagina  for,  207 
cure,    nntur:>i,    means   of  ob- 
taining, 191 
elytroplasty.  206 
essential  for  success  in,  186, 187 


786 


INDEX. 


Fistula,  vesico-vaginal — 
history,  185 
kolpoklfisis,  208 
operation  for,  191 

method     of    uniting    the 

edges,  204 
Gosset's  188 
Metzler's,  189 
Simon's,  199 

advantages  of,  201-203 
Sims's,  187,  192 
paring  the  edges  of,  193 
passing  the  needle,  19G 

the  sutures,  195 
physical  signs,  184 
position  of  the  patient,  200,  201 
preparation    of   the    patient, 

192 
prognosis,  184 
silver  wire  sutures  in,  197 
Sims  on,  184 
sutures,  192 

twisting  the,  197 
symjitonis,  183 
treatment,  191 

afterwards,  205 
vivifying  the  edges,  202 
Flexions  of  the  uterus,  390 
anatomy,  392 
causes,  exciting,  398 
jiretlisposing,  398 
comjilications,  397 
freiiuency,  391 
p.'ithology,  3;*4 

pathological  significance  of,  322 
results,  397 

sterility  caused  hy,  62G 
statistics,  391.  401 
Nonat's,  401 
Floating  kidney,  case  of,  417 
Follicular  degeneration  of  the  cervix  uteri, 
316 
causes,  317 
definition,  316 
pathology,  316 
prognosis,  317 
synonyms,  317 
treatment,  317 
vulvitis,  89 
Forceps;  dilating,  for  separating  the  blad- 
der and  vagina,  354 
Nelaton's,  in  fibroid  tumors,  514 
Form  of  patient's  history,  58 
Fossa  navicularis,  anatomy  of,  86 
Fungous    degeneration    of    the     uterine 
mucous  membrane,  treatmient  of,  609 


GALVANIC  pessary  in  amenorrhoea,  617 
Galvano-cautery,  632 
Byrne's,  632 

cancer,  removal  of,  by,  567 
cervix  uteri,  removal  of,  by,  308, 

633 
polypi,  removal  of,  by,  538 
G-angrenoiis  vulvitis,  92 
Gariel's  air-pessary,  176,  272 
Gas-jet  cautery,  570 
Gastrotomy,  removal  of  tumors  by,  518 
accidents  following,  521 
propriety  of  operation,  519 
statistics,  520 


General    considerations    upon    displace- 
ments of  the  uterus,  320 
anatomy,  324 
definition,  323 
general  causes,  325 
history,  320 

pathological    significance 
of  versions  and  tiexions, 
322 
synonyms,  323 
on   uterine   pathologj^  and  treat- 
ment, 216 
diagnosis,    imperfect, 

224 
hygiene,   general,  in- 
attention to,  226 
prognosis  in,  222 

erroneous,  in,  225 
therapeutics,  inappro- 
priate or  inefiicient, 
225 
treatment,  reasons  for 
frequent  failure  in, 
224 
Glands,  diseased,  Nabothian,  destruction 
or  ablation,  in  chronic  cervical  endo- 
metritis, 251 
vtilvo-vaginal,  cyst  and  abscess  of,  93 
Gonorrluca,  154 
causes,  155 
course,  156 
complications,  157 
definition,  154 
difierentiation,  155 
duration,  156 
Noeggerath  on,  156 
pathology,  154 
physical  signs,  155 
symptoms,  155 
termination,  156 
treattnent,  159 
"Granular  cell"  of  Drysdale  in  ovarian 
fluid,  671 
and  cvstic  degeneration  of  the  cervix 
uteri,  309 
Granulations,  cock's-comb,  of  the  cervix 

uteri,  314 
Gyutecology,  historical  sketch  of,  17 
list  of  desirable  works  on,  41 

HEMATOCELE,  pelvic,  488 
authors  upon,  list  of,  488 
causes,  491 

exciting,  492 

predisposing,  492 
course,  496 
definition,  488 
difl;erentiation,  495 

from  pelvic  iieritonitis,  476 
duration,  496 
frequency,  489 
history,  488 

operating,  methods  of,  498 
origin,  489 
pathology,  484 
physical  signs,  499 
prognosis,  496  \ 

source,  490  " 

symptoms,  493 
termination,  496 
treatment,  497 


INDEX. 


787 


Hnematocele — 

treatment,  medical,  499 
surgical,  498 
peritonea],  492 
pudendal,  99 
causes,  101 
course,  natural,  102 
definition,  99 

development,  mode  of,  100 
history,  99 
pathology,  100 
prognosis,  1(11 
symptoms,  101 
treatment,  102 
suhperitoueal,  492 
Hemorrhage  after  ovariotomy,  758 

from  inversion  of  the  uterus,  means 

of  arresting,  433 
pudendal,  98 
causes,  98 
symjitoms,  99 
treatment,  99 
Hernia,  pudendal,  102 
anatomy,  102 
causes,  103 
definition,  103 
symptoms,  103 
treatment,  104 
vaginal,  173 

cystocele,  173 
enterocele,  175 
rectocele,  174 

support,  supplementary,  176 
surgical  jiroeedures,  177 
treatment,  17(5 
ventral,  after  ovariotomy,  763 
Historical  sketch  of  gynaecology,  17 
History,  form  for  taking  patient's,  58 
Hydatids  or  parasitic  cysts  of  the  ovary,  678 
uterine,  576 
causes,  577 
definition,  576 
difierentiatiou,  578  • 

pathology,  577 
physical  signs,  578 
prognosis,  578 
symptoms,  577 
synonyms,  578 
treatTnent,  578 
Hydrocele,  104 
anatomy,  104 
case  of,  105 
definition,  104 
dift'erentiation,  106 
frequency,  104 
pathology,  105 
treatment,  lOii 
Hymen,  anatomy  of,  87 
Hypersesthesia  of  the  vulva,  114 
causes,  115 
definition,  114 
dift'erentiation,  115 
frequency,  115 
pathology,  115 
symptoms,  115 
treatment,  115 
Hyperplasia,  areolar,  of  the  uterus,  274. 
(See  Areolar  hyperplasia  of  the 

UTERUS.) 

Hysterotome,  Simpson's,  590 
Stohlniann's,  591 
White's,  592 


Hysterotomy,  cervical,  for  dysmenorrhcea, 
590 


1NCISIOX,  exjilorative,  in  ovarian  tu- 
mor, 700 
Inflammation,  phlegmonous,  of  labia  ma- 

jora,  96 
Inflammatory    or   congestive    dysmenor- 
rhcea, 584 
causes,  585 
definition,  584 
dift'erentiation,  585 
prognosis,  586 
symptoms,  585 
treatment,  586 
Injections  into  sac  in  ovarian  tumors,  714 
into  uterine  cavity,  266,  2(;7,  271,  272 
vaginal,  304,  305,  623 
Inspection  in  physicial  diagnosis,  64 
lutra-peritoneal     injections    of    water    in 
septicemia    following    ovariotomy, 
Peaslee  on,  762 
-uterine  scarification,  274 
stem  in  anteflexion,  409 
Inversion  of  the  uterus,  423 

amputating  uterus  in,  methods  of, 
449 
objections  to,  450 
anatomy,  424 
cases,  report  of,  440-447 

of  long  standing,  435 
causes,  exciting,  427 
predisposing,  426 
course,  431 
definition,  423 
dift'erentiation  from  fibroid,  430 

from  polyjius,  429 
dilator  used  in  reduction  of,  449 
duration,  431 
hemorrhage,  method  of  arresting, 

uterus  remaining  i7i  situ,  433 
pathology,  424 
physical  signs,  429 
prognosis,  431 

reduction,  gradual,  methods  of,  436 
Barrier's  method,  440 
by  elastic  pressure,  436 
by  stream  of  cold  water,  437 
Courty's  method,  440 
Noeggerath's  method,  440 
rapid,  by  taxis,  437 
Thomas's  method,  440 
White's  method,  439 
replacing,  methods  of,  434-435 
repositor,  436 
symptoms,  429 
sudden  case,  428 
Taylor  on,  426 
termination,  431 
treatment,  432 
varieties,  423 
Iodine,  injection  of,  in  the  sac  of  ovarian 
tumors,  715 

KIDNEY,  floating,  case  of,  417 
Knife,  Sims's,  for  operation  on  the 
cervix  uteri,  413 
Kolpokleisis,  or  operation  for  relief  of  uri- 
nary fistula,  208 


788 


INDEX, 


LABIA  majora,  anatomy  of,  86 
inflammation,  pliiegmonous,  of,  96 
diagnosis,  97 
symptoms,  96 
treatment,  97 
minora,  anatomy  of,  ^(j 
Laminaria  tents,  ]>reparati()U  of,  78 
Latero-flexion  of  the  uterus,  422 
Leucorrboea,  618 
causes,  621 
cervical,  621 
definition,  6:8 
frequency,  618 
history,  618 
pathology,  619 
prognosis,  622 
results,  622 
synonyms,  618 
treatnient,  622 
vaginal,  620 
varieties,  620 
Jjichen  of  vulva,  ^5 


MALIGNANT  papilloma.  556 
Manipulation,  conjoiueu,  iU  ]iliysical 
diagnosis,  62 
Marriage  with  imperfect  development  of 
ovaries,  640 
existing  uterine  disease,  52 
MembraiuMis  dysmenorrhoea,  593 
definitioix,  593 
difterentiation,  596 
etiology,  594 
frequency,  596 
membrane  in,  597 
pathology,  593 
prognosis,  597 
symptoms,  596 
treatment,  598 
sterility  caused  by,  626 
Menopause,  time  of  occurrence,  613 
Menorrhagia  and  metrorrhagia,  602 
causes,  603 
causing  sterility,  627 
caustic  treatment,  610 
curative  treatment,  607 
definition,  602 
difterentiation,  605 
factors  ill,  608 
frequency,  ()02 
pathology,  602 
prognosis,  606 
result,  606 
treatment,  606 

of   fungous    degeneration    of 
uterine  mucous  membrane, 
609 
caustic,  610 
curative,  607 
Menstrual    blood,    retained,    methods   of 
evacuating,  165 
treatment  of,  1(18 
Menstruation,  absence  of,  610 

disorders    of,    a   symptom    of  areolar 
hyperplasia,  293 
chronic  cervical  endometritis, 
241 
corporeal  endometritis,  261 
excessive  and  prolonged,  602 
excitants  of,  615 
batlis,  017 


Menstniation,  excitants  of — 
cupping,  616 
electricity,  616 
enemata,  stimulating,  017 
galvanic  pessary,  617 
passage  of  sound,  616 
tents,  616 
exposure  during   and  obstruction  to, 
causes  of  chronic   corporeal   endo- 
metritis, 258 
imprudence  during,  a  cause  of  i^elvic 
peritonitis,  470 
of  uterine  disease,  48 
suppression  of,  a  cause  of  acute  endo- 
metritis, 230 
tardy,  614 
Metalbumeu   in  ovarian  cvsts,   tests  for, 

6f)8 
Metritis,     chronic    parenchymatous,    274. 

(See  AREOLAK  HYPEltPL,A.SIA  OF  THE 
UTEKUS.) 

Metroi-rhagia  and  menorrhagia,  602 
causes,  603 
causing  sterility,  627 
caustic  treatment,  610 
curative  treatment,  607 
definition,  602 
difterentiation,  605 
factors  in,  608 
frequency,  602 
pathology,  602 
])rognosis,  606 
results,  606 
treatment,  606 
caustic,  610 
curative,  ()07 

of    fungous    degeneration    of 
uterine  mucous  membrane, 
609 
Microscope  as  a  means  of  physical  diag- 
nosis, 84 
Mineral   waters  in    treatment  of  areolar 

hyperplasia  of  the  uterus,  301 
Moles,  uterine,  574 
causes,  575 
definition,  574 
difterentintion,  .'^76 
history,  574 
pathology,  574 
physical  signs,  575 
prognosis,  576 
symptoms,  575 
treatment,  57(5 
Myo-fibromata   or  fibroid  tumors  of  the 
uterus,  499 


NABOTHIAN  glands,  238 
ablation   and   destruction   of,   in 
chronic  cervical   endometritis, 
251 
diseased,  in  chronic  cervical  endo- 
metritis, 238 
Narrovring  vagina,    Thomas's    operation 

for,  354 
Nervous   system,  excessive  development 

of,  a  cause  of  uterine  disease,  45 
Neuralgia  of  the  os  coccygis,  Nott's  ope- 
ration for,  120 
Neuralgic  dysmenorrhoea,  582 
causes,  582 
difterentiation,  583 


INDEX, 


789 


Nenrnlgic  dysmetiorrhcsa — 
pi-oguosis,  5.S3 
syinptums,  582 
treatmeDt,  583 


OBLITERATED   vagina,    operation    to 
render,  pervious,  166 
Obliteration    of    the    Fallopian    tubes,    a 

cause  of  sterility,  626 
Obstructive  dysinenorrbcea,  586 
causes,  587 
diiierentiation,  588 
patbology,  587 
prognosis,  588 
symptoms,  588 

treatment  of  cervical  constriction, 
589 
by  dilatntion,  58f) 
by  exjjanding  instru- 
ments, 589 
by  incising  the  cervix, 

590 
by  Priestley's  dilator, 

590 
by  tents,  589 

bysterotome,  Sim]>- 
son's,  590 
Stohlmann's,591 
White's,  592 
Sims's    metliod    of, 
590 
when  caused   by  dis- 
placements, 592 
polypus,  693 
of  fihrf)idK,  593 
of  obturator  hymen,  693 
of  vaginal  stricture,  593 
Obturator    bymen    and    fibroids    causing 

dysmenorrhoea,  treatment,  593 
Oophoritis,  acute,  ()44 
cases  of,  646 
causes,  647 
differentiation,  647 
pathology,  647 
prognosis,  648 
symptoms,  647 
treatment,  (!48 
Operation  of  abdominal  section  as  a  sub- 
stitute for  am])utation  in  inversion 
of  the  uttunis,  Tliomas's,  444 
of  amputation  of  the  cervix  uteri  by 
bistoury,  631 
by  ecraseur,  631 
by  galvano-cautery,  632 
by  scissors,  631 
of  the  uterus  for  inversion,  461 
for  atresia  A'agin?^  166 
cervical  glands,  removal  of,  Thomas's, 

252 
for  coccyodynia,  Nott's,  121 
for  drainage  of  ovarian  tumors,  707 
Kiwisch's,  709 
Noeggerath's,  709 
Schnetter's,  709 
West's,  I'lO 
for  enlarging  the  cervix  uteri  for  ste 

rility,  591,  628 
of  episiorrhaphy  for  prolapsus  vaginae 

and  vaginal  hernia,  177 
for  evacuating  jielvic  abscess,  486 
hematocele,  498 


Operation — 

for,  fibroid  tumors  of  uterus,  removal 
of,  by  avulsion,  516 
by  ecrasement,  514 
by  enucleation,  516 
by  excision,  514 
for  fistulre  in volving  extensive  destruc- 
tion of  the  base  of  the  bladder, 
Bozeman's,  210 
fecal,  by  suture  of,  214 
urinary,  closure  of  vagina  for,  206 
cross  obliteration  of  the  vagina 
or  kolpokleisis,  Simon's,  208 
elytroplasty,  206 
Gosset's,  188 

kolpokleisis,  or  cross  oblitera- 
tion of  the  vagina,  Simon's, 
208 
Simon's,  199 
Sims's,  192 
vesico-uterine,  209 
for  flexions  of  the  uterus,  to  obviate 

the  consequence  of,  Sims's,  412 
of  gastrotomy  for  removal  of  uterine 

filiroids,  518 
of   hysterotomy    for    dysmenorrhoea, 
Simpson's,  590 
Sims's,  591 
of  ovariotomy,  742 
abdominal,  738 
vaginal,  732 
of  paracentesis  for  ovarian  tumors,  702 
through  abdominal  walls,  704 
rectum,  706 
vaginal  walls,  705 
of  perineorrhaphy,  130 
for,  perineum,  ruptured,  133,  138 

time  for  performance,  129 
for  polypi,  uterine,  removal  of,  536 
for    prolapsus    uteri,    e^vtrorrhaphy, 
Emmet's,  352 
Sims's,  351 
Thomas's,  354 
for  vagina,  narrowing  the,  Thomas's, 

354 
vaginismus,    Simpson's    modification 
of  Burns's,  148 
Sims's,  147 
for  vnlvo-vaginal  glands,  extirpation 
of,  94 
Opium  in  cancer  of  the  uterus,  571 
Os  coccygis.  operation  for  relief  of  neural- 
gia of,  120 
iiteri,  dilatation  a  symptom  of  chronic 
corporeal  eiulometritis,  263 
obstruction  of,  a  cause  of  chronic 

corporeal  endo!netritis,  25H 
plugging  of,  in  ajjplying  leeches  to 
the  cervix  uteri,  302 
Ovarian  cysts  and  cystomata,  662 
ailenoma,  664 
age  of  occurrence,  673 
asjiiration  in,  698 
causes,  673 

conditions  likely  to  complicate,  677 
contents  of,  (UKJ 

of  chemical  constituents  of,  6()7 
cure,  spontaneous,  of,  (i75 
death,    melhods    by    which,    pro- 
duced, 677 
deriiii'id,  ("-."S 

age  of  occurrence,  659 


790 


INDEX. 


Ovarian  cysts,  dermoid — 
case  of,  1)59 
diagnosis,  682,  687 

conditions   likely   to   mislead 

in,  687 
crucial  test  in,  698 
existence  of  a  tumor,  683 
"Is  the  tumor  ovarian?"  684 
rules  for  avoiding  errors  in,  701 
differentiation     from     abdominal 
viscera, distension  of,  6-i!i 
walls,  abnormal  thickne.'^s 
or  tension  of,  688 
from  amniotic  dropsy,  695 
from  ascites,  ()9IJ 
from  broad  ligament,  cysts  of, 

677 
from   cystic  disease  in  other 

parts  of  the  abdomen,  6U2 
from  diseased  states  of  pelvic 
walls  and  areolar  tissue,  69() 
from  ilropsy,  tubal,  (579 
from  fluid  peritoneal  accumu- 
lations, 690 
from  hydatids,  678 
fr(un  jiregnancy,  694 
from   sjiinal  cord,  cysts  con- 
nected with,  681 
from  subperitoneal  cysts,  6^0 
from  uterine  fibro-cysts,  ()93 
from  viscera,  excessive  devel- 
opment or  dispiacements  of 
other,  694 
diseased  conditions  affecting,  675 
explorative  iiicisit)n  in,  700 
"granular  cell"  of  Drysdale,  671 
history,  natural,  of,  674 
metalhumen,  test  for,  (568 
microscopical  appearance  of  fluid 

contained  in,  669 
monocysts,  665 
multilocular,  664 
paralbumen,  test  for,  667 
parasitic,  678 
pathology,  663 
paucilocular,  665 
pedicle,  length  of,  697 
physical  exploration,  means  of,  685 

signs,  6N3 
removal    of,    717.     (See    Ovaui- 

OTOMY.) 

symptoms,  681 
tapping  of,  700,  702 
treatment,  701 
varieties,  664 
dys.menorrhoea,  600 
detiiiiTioUi  6110 
pathology,  601 
prognosis,  601 
symptoms,  600 
treatment,  (iOl 
infiamraation.  Tilt's  views  on,  .35 
tumiirs,  ()51 

adinioma,  6G4 
atlipose,  659 
carcinoma,  653 

symptoms,  6.>4 

varieties  of,  653 
cysto-carcinoma,  656 
-fibroma,  (;57 
-sarcinun,  657 
case  of,  657 


Ovarian  tumors,  cysto-sai'coma — 

operation  for,  results  of,  658 
size  to   which   they    may 

attain,  657 
tendency  of  these  growths, 

658 
treatment,  658 
colloid  degeneration,  660,  661 
definition,  660 
operation  for,  662 
cysts  and   cystomata,  662.     (See 

OVAKIAN  CYSTS.) 

dermoid,  658,  659 

fibroma  or  fibrous  tumor,  655 

pileous,  658,  659 

tendency    of    cysto-fibroma    and 

cysto-sarcoma,  658 
treatment,  drainage  in,  707 

Kiwisch's  method,  709 
Noeggerath's  method,  709 
Schnetter's  method,  709 
West's  method,  710 
incision  in,  711 

table  of  statistics,  713 
injection  into  the  sac,  714 
statistics,  715 
tapping,  rules  for,  705 
through  rectum,  706 

vaginal  w.ills,  705,  708 
palliative,  resume  of,  716 
varieties,  652 
Ovaries,  apojih-xy  of,  642 
definition,  642 
prognosis,  ()43 
symptoms,  642 
treatment,  643 
atrophj'  of,  641 
causes,  641 
treatment,  642 
development,  imperfect,  of,  638 
electricity  in,  640 
marriage  with,  640 
treatment  for,  640 
uterine  irritation  in,  640 
diseases  of,  634 
absence  of,  638 
anatomy,  635 
history,"^634 
table  of,  635 
displacements  of,  643 
treatment,  641 
Ovariotomy,  717 
abdominal,  738 

supporter  after,  763 
advantages  of,  724 
after-m.inagement,  757 
applications  to  abdomen,  after,  762 
clam]),  time  of  removal,  after,  763 
Dawson's  temp^iary,  748 

l)ermanent,  750 
French,  750 
Spencer  Wells's,  749 
clamp-sliield,   Sirirer's,  7.52 
conditions  favorable  to  the  operation, 
729 
unfavorable  to  the  operation,  731 
dangers  following,  758 

of,  724,  725 
definition,  717 

hemorrha.L'e  after,  treatment  of,  758 
history,  717 
operation,  742 


INDEX. 


791 


Ovariotomy,  operation — 

actual    cautery    in,  Baker  Brown 

on,  7.j2 
adhesions,    examination    for    and 

rupture  of,  745 
of,   clamp,  Dawson's   terajiorary, 
748 
permanent,  750 
French,  750 

Spencer  Wells's,  for  securing 
the  )iedicle,  749 
of,  clamp-shield,  Storer's,  752 
of,  closing  the  wound  after,  7."6 
of,  drainage,  establishment  of,  755 
of,  tlrainage-tube,  glass, Thomas's, 
756 
per  vaginam,  755 
of,  enucleation  of  tumor,  751 

by  Miner's  method,  744 
of,  incision,  742 

length  of,  743 
of,  ligatures  in,  747,  753 
of,  omentum,  removal  of,  754 
of,  ovary  remaining,  examination 

of,  754 
of,  iJ(;dicle,  returning   to    the   ab- 
dominal cavity,  751,  753 
securing  the,  748 

methods  of,  749 
suggestion  for  applying dift'er- 

ent  plans,  752 
treatment  of,  statistics,  753 
of,  peritoneum,  cleansing  the,  755 
of,  sac,  obstacle   to   the   removal 
of,  753 
removal  of,  747 
of,  steps  in  the,  742 
of,  tapping,  746 

of,  trocar,  Spencer  Wells's  in,  746 
peritonitis  following,  762,  763 

treatment  of,  762 
preparation  for  the  operation,  740 
preparatory  treatment,  741 
rules  for  the  avoidance  of  dangers  in, 

726 
septicaemia  after,  758 

intra-peritoneal       injections, 

Peaslee  on,  7(52 
means  of  avoiding,  759 
symptoms,  758 
washing  out    the    peritonea] 

cavity  for,  756 
temperature  in,  760 
statistics,  726 

table  of,  729 
sutures,  time  for  removing  after,  763 
vaginal,  732 

Battey's  case  of,  737 
Gilmore's  case  of,  736 
Thomas's  case  of,  732 
varieties,  723 
ventral  hernia  after,  763 
double,  treatment  of  pedicle  in,  751 
Ovaritis,  acute,  ()44 
cases,  646 
causes,  647 
differentiation,  647 
patholojiy,  647 
prognosis,  648 
symptoms,  647 
treatment,  648 
chronic,  648 


Ovaritis,  chronic — 

prognosis,  650 
signs,  physical,  650 

rational,  649 
symptoms,  619 
treatment,  650 


pALPATIOX,   abdominal,   in   physical 
£  examination,  63 

conjoined  with  the  use  of 
the  sound, 63 
bimanual,  in  physical  examination,  62 
Papilloma,  uterine,  benign,  556 

malignant,  556 
Paracentesis  in  ovarian  dropsy,  702 

abdominal  walls  through  the, 

704 
cases  cured  by,  703 
danger  of,  702 

diagnosis  as  a  means  of,  698 
disadvantages  of,  702 
means  of  relief,  as  a,  702 
rectum,  through  the,  706 
vaginal  walls,  through  the,  705, 
708 
Paralbumen  in  ovarian  cysts,  test  for,  667 
Parasitic  or  hydatid  cysts,  678 
Parturition,  imprudence  after,  a  cause  of 

uterine  disease,  49 
Pathology  and  treatment,  uterine,  genernl 
considerations  upon,  216 
theories  about,  220 
uterine,  historical  sketch  of,  30 
Pedicle  of  ovarian  tumor,  length  of,  697 
long,  697 
short,  (I'JT 
twisted,  697 
Pelvic  abscess,  481 
causes,  482 
course,  482 
definition,  481 
difierentiation,  483 
duration,  482 

evacuation,  best  point  for,  486 
methods  of  operating  upon,  486 
jiathology,  4.S1 
physical  signs,  4X2 
prognosis,  484 
puncture  i)er  vaginam,  485 
routes  fVir  discharge  of,  48  5 
sac,  means  of  closure  of,  487 
symptoms,  ■182 
termination,  482 
treatmenf,  4S4 
Pelvic  hfematocele,  4'  8 

authors  njion,  list  of,  488 
causes,  491 

exciting,  492 
predisposing,  492 
course,  496 
definition,  488 
dift'erentiatinn,  495 

from  lie!  vie  peritonitis,  476 
duration,  4!i6 
fre(iuency,  489 
history,  48K 

operating,  meth<Mls  of,  498 
origin,  4Mt 
pathology,  4f^'9 
physical  signs,  494 
prognosis,  496 


792 


INDEX. 


Pelvic  hsematocele — 
source,  4^0 
symptoms,  493 
termination,  496 
treatment,  497 
medical,  499 
stirgical,  498 
Pelvic  peritonitis,  465 
case  of,  467 
causes,  470 
course,  475 
definition,  465 
differentiation,  476 

from  Iccal  iuiiiaction,  477 
from  fibrous  tumor,  477 
from  pelvic  hii'matocele,  476 
from  ]>eriuteriue  cellulitis,  476 
duration,  475 
evacuation  of  pus  and  serum,  480 

methods  of,  481 
frequency,  468 

general  proposition  concerning,  466 
history,  465 
pathology,  468 

pelvic  cellulitis,  importance  of  dif- 
ferentiating from,  477 
physical  signs,  474 
prognosis,  477 
results,  478 

"roof  of  the  pelvis, "469 
symj)tonis,  472 
termination,  475 
treatment,  478 

of  chronic  cases,  479 
varieties,  472 
Pelvic  walls,  diseased  state  of,  diflfei-entia- 

tion  from  ovarian  tumor,  696 
Pelvis,  means   of   exploring  viscera   and 
tissues  of,  85 
"roof  of,"  469 
Percussion  as  a  means  of  physical  diag- 
nosis, 85 
Perineal  support  for  prolapsus  uteri,  3!9 
Perineorrhaiiliy,  i:?l,  133,  134.  135,  138,  349 
Perineum,  ruptured,  125 
anatomy,  lL.'5 
causes,  128 
consequences,  127 
degrees,  127 

evils  resulting  from,  127 
instruments  and  appliances  need- 
ed in  operation  for  relief  of,  133 
operation  for  complete,  138 
for  iiartial,  133 
stei)s  in,  134,  135 
time  for,  129 
patient,  preparation  of,  132 
prognosis,  128 
resultsof,  127 
resume,  140 

sutures,  means  of  preventing  ten- 
sion on,  136 
time  for  removal  after  opera- 
tion, 137 
treatment  at  time  of  occurrence, 
129 
of  cases  which  have  cicatrized, 
131 
varieties,  127 
Peritoneal  accumulations,  fluid,  differen- 
tiated from  ovarian  tumor,  690 
Peritoneo-vagiiial  fistul£e,  215 


Peritonitis  following  ovariotomy,  762,  763 
treatment  of,  762 
pelvic,  465 

case  of,  467 
caitses,  470 
course,  475 
definition,  4(55 
diflterentiation,  476 

from  fecal  impaction,  477 
from  fibrous  tumor,  477 
from  i)elvic  hajmatocele,  476 
from  ])eriuterine  cellulitis,  476 
duration,  475 
evacuation  of  pus  and  serum,  48(i 

methods  of,  481 
frequency,  468 
general   propositions    concerning, 

466 
history,  465 
pathology,  468 
pelvic    cellulitis,    importance    of 

differentiating  fiom,  477 
physical  signs,  474 
prognosis,  477 
results,  478 

"  roof  of  the  pelvis,"  469 
symptoms,  472 
t<!rmination,  475 
treatment,  478 

of  chronic  cases,  479 
varieties,  472 
Periuterine  cellulitis,  452 
anatomy,  453 
causes,  458 
complications,  456 
consequences,  462 
course,  457 
definition,  453 
differentiation,  462 
duration,  457 
fre<inency,  453 
history,  452 
patliology,  454 
physical  signs,  460 
post-mortem    records,    table     of, 

4.-.5 
prognosis,  458 
symptoms,  459 
synonyms,  453 
termination,  457 
treatment,  462 
Pessaries,  air-,  Gariel's,  176,  272 
antefiexion,  406 
anteversion,  366,  368,  370 
maxims  for  using,  371 
Thomas's,  368,  369 
Cutter's    (modified),  for  anteversion, 
.S70 
for  prolapsus,  348 
for  retroversion,  385 
galvanic,  in  amenorrhoea,  617 
general  remarks  upon  the  use  of,  346 
Hewitt's  anteversion,  371 

retroversion,  386 
Hitchcock's  anteversion,  369 
Hodge's  retroversion,  384 
Hoffman's  retroversion,  382 
Hurd's  anteflexion,  408 

i-etroflexion,  421 
intra-nterine  stem,  409 

for  anteflexion,  411 
galvanic,  617 


INDEX. 


793 


Pessaries — 

Meigs's  ring,  386,  3S7 

prolapsus  uteri,  used  for,  34G,  348 

retroriexion,  420 

Thomas's,  419 
retroversion,  385 
ring,  Meigs's,  380,  387 
Smith's,  Albert,  retroversion,  384 
Thomas's  anteversion,  36s,  36!t 

modification  of  Cutter's  retrover- 
sion, 383 
retrotiexion,  419,  420 
Phlegmonous   inflammation  of  the   labia 
majora,  96 
symptoms,  96 
treatment,  97 
Physical  diagnosis,  means  of,  60 
Polyptome,  Aveling's,  514 

Simpson's,  537 
Polypus,  uterine,  530 
causes,  532 
causing  dysmenorrhcea,  treatment 

of,  593  ' 
cellular,  531 
complications,  534 
course,  534 
definition,  530 
differentiation,  534 

from   iuversiou  of  the  uterus, 
429 
ecrasement,  removal  by,  537 
excision  of,  636 
fibrous,  531,  532 
galvano-caustic  wire,  removal  of, 

by,  538 
glandular,  531,  532 
history,  530 

pathological  an;ttomy,  531 
physical  signs,  533 
prognosis,  534 
symptoms,  533 
termination,  534 
torsion,  removal  of,  by,  536 
traction,  I'emoval  of,  by,  536 
treatment,  curative,  536 

palliative,  533 
varieties,  530 
Position  for  introducing  Sims's  speculum, 

72 
Potassa  cnm  calce,  mode  of  applying  to 

cancer  of  the  uterus,  570 
Pregnancy,  differentiation   from    ovarian 

tumor,  694 
Probe,  Budd's  elastic,  249 

Lente's  silver  caustic,  250 

Sims's,  for  application  to  the  cervix 

uteri,  251 
Thomas's  elastic,  76,  518 
uterine,  74,  75 
uses  of,  73 
Probing  the  uterus,  method  of,  75 
Procidentif.  of  the  uterus,  328.    (See  Pro- 
lapsus UTEKI.) 
Prolapsus  urethra',  119 
treatment,  119 
uteri,  328 

acute  and  sudden,  342 
amputation  of  the  cervix  uteri  for, 

345,  629,  630 
anatomy,  328 
astringents  in,  345 
causes,  330,  333,  334,  335 


Prolapsus  uteri — 

clamp,  toothed,  used  in  Thomas's 
operation     for     narrowing     the 
vagina,  355 
complications,  341 
course,  338 
definition,  328 
diagram,  329 
ditierentiation,  340 
dilating  forceps  used  in  Thomas's 
operation     of     narrowing     the 
vagina,  354 
duration,  338 
elytrorrhaphy,  350 
episiorrhaphy  fur,  177,  357 
frequency,  3:^8 

Gueniot's  deductions  upon,  337 
cedematous  elongation  with  pro- 

lajise  of  neck,  337 
operation  for   narrowing  vagina, 
350 
Enimett's,  352 
Sims's,  351 
Thomas's,  354 
pathology,  332 
perineal  support,  349 
perineorrhaphy,  349 
pessaries,  346 
physical  signs,  339 
pressure   from    above,    means   of 

preventing,  344 
prognosis,  340 

replacing  uterus, methods of,in,342 
sudden  and  acute,  342 
sustaining  uterus,  methods  of,  343 
symptoms,  339 
synonyms,  328 
termination,  338 
tonics  in,  345 

traciion  by  vagina,  means  of  pre- 
venting, 349 
treatment,  342 

uterine      supports,      means      of 

strengthening   and    suijjjle- 

menting,  345 

weights,  means  of  diminishing, 

345 

vagina,    Tlmmas's    operation   for 

narrowing,  354 
varieties,  329 
vagina^,  169 
causes,  172 

complications,  173,  174 
course,  172 
definition,  169 
duration,  172 
pathology,  1.1 
])rognosis,  173 
surgical  procedures,  177 
symptoms,  173 
synonyms,  169 
termination,  172 
treatment,  176 
varieties,  172 
Prurigo  of  the  vulva,  95 
Pruritus  vulva\  li  6 
causes,  108 
course,  107 
definition,  106 
develojinicMt,  mode  of,  107 
etiology,  1(18 
pathology,  106 


794 

Pruritus  vnlvfe — 

ticiitiuent,  110 
Pudeudiil  hematocele,  99 
causes,  101 
course,  natural,  102 
definitinn,  90 

development,  mode  ot,  lUU 
history,  !t9 
pathology,  100 
prognosis,  101 
symptoms,  101 
treatment,  102 
hemorrhage,  98 

causes,  9S 

symptoms,  99 

treatment,  99 
hernia,  102 

anatomy,  102 

causes,  103 

definition,  103 

symptoms,  103 

treatment,  104 
Purulent  vulvitis,  87 

causes,  88 

course,  88 

symptoms,  88 

termination,  88 

treatment,  89 


INDEX. 


r>EASONS  for  the  frequency  of  failure  in 
\j  the  treatment  of  uteniu^ 

disease,  224 
diagnosis,  imperfect,  224 
hvgicne,      and,     manage- 
'ment,  general,  inatten- 
tion to,  1:26 
prognosis,  erroneous,    in, 

225 
therapeutics,    inappropri- 
ate or  inethcieut,  225 
Rectal  touch  in  physical  diagnosis,  ()4 
liectocele,  174  „         ,  *     • 

as  a  complication  of  prolapsus  uteri, 

342 
■Recto-vesical  expl'^ation,  60 
Keduction  of  inverted  uterus,  rapid,  ^"i 

gradual,  436 
Replacing  uterus,  methods  of,  342 
Reposilor,  \iterine,  436 
Siebold's,  436 
Sims's,  379 
AVhite's,  439 
Retroflexion  of  the  uterus,  415 
consequences,  417 
definition,  415 
differentiation,  416 
pessaries  for,  420 
for,  Kurd's,  421 
for,  Thomas's,  419 
physical  signs,  415 
prognosis,  418 
symptoms,  415 
treatment  lor  irreducible  cases,  42 

for  reducible  cases,  418 
varieties,  415 
Retxoversion  of  the  uterus,  373 

Bond's  method  of  reduction,  o7;> 
causes,  exciting,  373 
predisposing,  373 
definition,  373 
differentiation,  377 


Retroversion  of  the  uterus — 
frequency,  373 
Hoffnian's  jjessary  in,  382 
pessaries  in,  380 

in.  Cutter's,  385 

Thomas's  modification  of, 
385 
in,  Hewitt's,  386 
in,  Hodge's,  384 
in,  Hotl'man's,  382 
in,  Meigs's  ring,  386,  387 
in,  Smith's,  Albert,  384 
•  physical  signs,  377 
prognosis,  377 
reduction,  methods  of,  378 
results,  377  _ 

retention,  methods  of,  3i9 
symptoms,  376 
tampon  in,  381 

treatment   of    posterior  displace- 
ments in  which  version  predomi- 
nates, 377 
uterine  repositor,  Sims  s,  379 
varieties,  375 
Ring  pessary,  Meigs's,  Sf^e,  387 
"  Roof  of  the  pelvis,"  469 
Rupture  of  the  perineum,  125 
anatomy,  125 
causes,  128 
consequences,  127 
degrees,  127 

evils  resulting  trom,  12( 
instruments        and        appliances 
needed  in  the  operatnm  tor,  133 
operation  for  complete,  138 
for  partial,  133 
for,  steps  in,  134,  135 
for,  appliances  required,  133 
preparation  of  the  patient,  132 
prognosis,  128 
resume,  140 
time  for  operation,  129 
treatment  at  time  of  occurrence, 

129  .        .      , 

of  cases  which  have  cicat  nzeU, 

131 
varieties,  127 


SATjPTXGTTIS  or  inflammation  of  the 
Fallopian  tubes,  706 
Sarcoma  of  the  uterus,  539 
causes,  541 
course,  542 
definition,  540 
difterentiation,  542 
duration,  542 
frequency,  540 
history,  539 
pathology,  540 
physical  signs,  542 
prognosis,  543 
symptoms,  542 
synonyms,  540 
termination.  542 
treatment,  543 
Scarification,  intra-uterine,  2(4 
Scarificator,  Buttle's  uterine,  303 
SdssorF.,  double,   for   slitting  the   cervix 

uteri,  414 
Sclerosis  of  the  uterus,  288 
Scoop,  Simon's,  569 


JNDEX, 


795 


Sea-tangle  tents,  78 

]nei)aration  of,  78 
Septicagmia  following  ovariotomy,  758 
avoiding,  means  of,  759 
injections,       intra-peritoneal, 

Peaslee  on,  762 
symptoms,  758 
temperature  in,  760 
table  of,  760,  761 
treatment  of,  760,  761 
Signs,  rational,  used  in  diagnosis,  57 
Silver-wire  sutures  in  ve.sico-vaginal  fis- 
tula, 187,  197 
Simon's  method  of  i)liysical  examination, 

65 
Skirt-sujiporter,  Bacbeller's,  301 
Sound,  uterine,  73 

abdominal    palpation,    conjoined 

with,  in  physical  diagnosis,  63 
ancient  writers,  mentioned  by,  24, 

25 
dangers  of,  73 
diagnosis,  as  a  means  of,  in  uterine 

disease,  73 
discovery  of,  73 
facts  ascertained  by,  74 
injury  from,   a   cause   of  chronic 

corporeal  endometritis,  258 
Kiwisch's,  73 
metal,  for  dilating  the  cervix  uteri 

in  dysmenorrlujea,  689 
mode  of  introduction,  73 
passage  of,  in  amenorrhoea,  616 
Sims's,  with  sharp  points,  351 

and  Simpson's,  compared,  75 
Valleix's,  73 
Spanseraia   distinguished  from   chlorosis, 

771 
Speculum,  66 

ancient  valvular,  23 
cervical,  Wylie's,  264 
Charriere's,  68 
Cusco's,  68 

diagnosis,  a  means  of,  in  uterine  dis- 
ease, 66 
Fergusson's,  67 
Hunter's,  71 

mention  of,  by  ancient  vi^riters,  23,  25 
method   of  introducing  valvular  and 
cvlindrical,  71 
Sims's,  69,  72 
Neugebauer's,  68 
Nott's,  70 

physical  examination,  in,  66 
Eicord's,  68 
Segalas's,  68 
Sims's,  38,  69 

method  of  introducing,  72 
telescopic,  Thumas's,  67 
Thomas's  modification  of  Sims's,  71 
valvular,  68 

method  of  introduction,  71 
Wylie's  cervical,  264 
Spinal  cord,  cysts  connected  with,  681 
Sjjonge  tents,  77 

amenorrhoea,  use  in,  615 

dangers  of,  80 

fatal  results  caused  by,  81 

medicated,  77 

mode  of  introducing,  79,  80 

Nott's,  78 

on  the  respective  merits  of,  79 


Sponge  tents — 

physical  diagnosis,  as  a  means  of, 

77 
precautions     to    be    observed     in 

using,  82 
rules    to    be    observed    in    intro- 
ducing, 82 
sponge  compared  with  sea-tangle, 

78 
use  in  amenorrhoea,  615 

in    chronic    cervical   endome- 
tritis, 247 
in    neuralgic    dysmenorrhoea, 

584 
In  obstructive  dysmenorrhoea, 
589 
Stems,  intra-uterine,  in  autctiexion,  409 
Sterility,  624 
causes,  624 
conoidal  cervix,  626 
definition,  624 
differentiation,  627 
endometritis,  a  cause  of,  625 
flexion,  625 
history,  624 
membranous  dysmenorrhoea,  a  cause 

of,  626 
prognosis,  627 
results,  628 
synonyms,  624 
treatment,  628 
tubes,    obliteration    of,    a    cause    of, 

625 
vaginismus,  a  cause  of,  625 
Stricture  or  the  Pallopiau  tubes,  768 
causes,  768 
of  the  vagina,  a  cause  of  obstructive 

dysmenorrhoea,  587 
of  the  cervix  uteri,  a  cause  of  obstruc- 
tive dysmenorrhoea,  587 
treatment,  589,  590 
Subinvolution   of  the   uterus,   a  cause  of 
areolar  hyperplasia,  285 
of  uterine  disease,  219 
Subperitoneal  cysts,  680 

hfematocele,  492 
Suppositories,  vaginal,  in  afiecfions  of  tlm 
cervix  uteri,  315 
in  vaginitis,  160 
tubes  for,  160 
Sutures,   time  for    removal    after    ovari- 
otomy, 763 
in  ruptured  perineum,  135,  136 

means  of  jireventing    tension 

on,  136 
time  for  removal  after  opera- 
tion for,  138 
in  urinary  fistuhe,  192 

mode  of  passing,  195 
mode  of  twisting,  197 
silver  wire,  187,  197 
Syphilides  of  vulva,  96 
Syphilitic  ulcer  of  the  cervix  uteri,  318 
Syringe,    cervical     mucus,    for    removal 
of,  247 
Davidson's,  304 
Essex,  304 
fountain,  305 

hard  rubber,  for  cupping  cervix  uteri, 
304,  616 
for  removing  cervical  mucu.v 
247 


796 


INDEX. 


Syringe — 

Leute's  ointment,  265 
Molesvvorth's,  for   uterine  injections, 
272 
vaginal,  305 


TAMPON  in  puaend.-il  liemorrhage,  99 
in  retr(jversiuii,  381 
Tapiting  iu  ovarian  tumors,  702 

through  the  abcloiuinal  walls, 

704 
diagnosis,  as  a  means  of,  700, 

702 
fluid,    large    amount    of,    ob- 
tained by,  703 
operation  at  tli(>  time  of,  74G 
through  tli(!  rectum,  TOG 
rules  for,  705 
statistics,  703 

through    the    vaginal    walls, 
705 
Taxis    in     rapid    reduction    of    inverted 

uterus,  437 
Temperature  in  septica;mia  following  ova- 
riotomy, 7()') 
tables  of,'7(ii>,  761 
Tenaculum  for  fixing  the  uterus,  80 
Tents,  77 

in  amenorrhcea,  615 
dangers  of,  80 
fatal  results  caused  by,  81 
Greenhalgh's,  78 
laminaria,  78 

advantages  of,  78 
disiulvautages  of,    78 
mode  of  i>reparation,  78 
medicated,  77 

mode  of  introducing,  79,  80 
Nott's,  78 

on  the  res|)eotive  merits  of,  79 
ph.ysical  diagnosis  as  a  means  oi',  77 
])recautions  to  be  observed  in  using,  82 
rides  to  be  observed  iu  iuti'oduciug,  82 
sea-tangle,  78 
sponge,  77 

compared  with  sen-tangle,  78 
use  in  amenorrhcea,  615 

in  chronic   cervical  endometritis, 

247 
in  neuralgic  dysmenorrhoea,  584 
obstructive  dysineuorrlue:),  58!) 
Touch,  rectal,  in  physical  diagnnsis,  64 

vaginal,  in  physical  dingnnsis,  6> 
Tubal  dropsy  of  the  Fallopian  tubes,  709 
Tube,  suppositorv,  160 
Tumors,  fluid,  652 

ovarian  cysts  and  cystomata,  602 
parasitic  or  hydaiid  cysts,  678 
varieties,  652 
ovarii n,  651 

adenoma,  664 
adipose,  65!) 
carcinoma,  6."3 
symptuiMs,  654 
varieties,  653 
cysto-carcinoma,  656 
cysto-fibroma,  657 
cysto-sarcoma,  657 
case  of,  657 

operation   for,  results   of, 
658 


Tumors,  ovarian,  cysto-sarcoma — 

size    to    which    they    may 

attain,  657 
tendency  of  these  growths, 

658 
treatment,  658 
colloid  degeneration,  660,  661 
definition,  tiOO 
operarion  for,  662 
cysts  and  cystomata,  662 
adenoma,  664 
age  of  occurrence,  673 
aspiration  in,  698 
causes,  673 

conditions  likely  to  com- 
plicate, 677 
contents  of,  666 

of    chemical    constit- 
uents of,  667 
cure,  spontaneous,  of,  675 
death,  methods  by  which 

produced,  677 
dermoid,  658 

age  of  occurrence,  659 
case  of,  (!59 
diagnosis,  conditions  like- 
ly to  mislead  in,  687 
crucial  test  in,  698 
existence  of  a  tumor, 

683 
*'  is    the    tumor    ova- 
rian ?"  684 
rules      for      avoiding 
errors  in,  701 
differentiation     from    ab- 
dominal viscera, dis- 
tention of,  6S9 
from  alidominal  walls, 
al)normal  tliickness 
and    distention    of, 
588 
from  amniotic  dropsy, 

695 
from  ascites,  692 
from  broad   ligaments 

cysts  of,  677 
from  cystic  disease  in 
Other   parts    of    the 
abdomen,  692 
from  diseased  state  of 
the  ])elvic  walls  ;uid 
areolar  tissues,  6!)() 
from  diopsy,  tubal.(;8(> 
from    Huid  j)eritoneal 

accumulation,  (iOO 
from  hydatids,  (i78 
from  pregnancy,  694 
from  spinal  coi-c'.cysrs 
connected  with,  681 
from       subperitoneal 

cysts,  680 
from     uterine     fibro- 

cysts,  693 
from    viscera,    exces- 
sive     development 
or  displacement   of 
other,  694 
diseased  conditions  affect- 
ing, 675 
exphu-ative incision  in,  700 
"granular  cell"  of  Drvs- 
dale,  671 


INDEX. 


797 


Tumors,  ovarian  cysts  and  cystomata — 
history,  natural  of,  674 
metalbuiiieu,  test  for,  (ilJS 
microscopical  appearance 
of   fluid    contained    in, 
6(J9 
monocysts,  665 
multilocular,  664 
paralbumen,  test  for,  667 
parasitic,  678 
pathology,  663 
paucilocular,  665 
pedicle,  length  of,  697 
physical   exploration, 
means  of,  685 
signs,  683 
removal  of,  717 
syin]itoms,  681 
tapi)ing  of,  7(tO,  702 
treatment,  701 
varieties,  664 
dermoid,  668,  659 

age  of  occurrence,  659 
case  of,  659 
size  of,  659 
fibroma  or  fibrous  tumor,  655 
pileous,  658,  659 
tendency    of    cysto-fibronia     and 

cysto-sarcoma,  658 
treatment,  drainage  in,  707 

Kiwisch's  method,  709 
Noeggerath's  method,  709 
Schnetter's  method,  709 
West's  method,  710 
incision  in,  71 1 

table  of  statistics,  713 
injection  into  the  sac,  714 
statistics,  715 
tapi^ing,  rules  for,  705 
through  rectum,  706 

Yagiiial  walls,  705,  708 
palliative,  resume  of,  716 
varieties,  752 
periuterine,  fiuid,  cysts  of  broad  liga- 
ment, 677 
diagnosis,  678 
prognosis,  678 
treatment,  678 
of     spinal      cord,     connected 

with,  681 
subperitoneal,  680 
tubal  dropsy,  680 

diagnosis,  means  of,  680 
size  of,  680 
solid,  652 

adenoma,  664 
adipose,  659 
carcinoma,  653 

symptoms,  654 
varieties,  653 
dermoid,  658 

age  of  occurrence,  659 
case  of,  659 
size  of,  659 
fibroma  or  fibrous  tumor,  655 
uterine,  cancer  of  the  uttunis,  543 
causes  exciting,  559 

predisposing,  557 
caustics  in,  5()8,  570 
complications,  563 
conslitutional  treatment,  572 
defiuition,  543 


Tumors,  uterine,  cancer — 

diti'erentiation,  "61 
of  cancer  of  the  body,  565 
encephaloid,  r)46 
epithelioma,  516,  549 

vegetating,  554,  555,  557 
frequency,  relative,  of  dilier- 

ent  varieties,  547 
galvano-cautery  in,  567 
gas-jet  cautery  in,  570 
history,  554 

malignant  paiiilloma,  555 
opium  in,  571 

parts  of  uterus  afl'ected,  563 
pathology,  5!4 
peculiar  features  of  cancer  of 

the  body,  564 
physical  signs,  560 
prognosis,  562 
scirrhus,  546,  549 
Simon's  scoop  in,  569 
statistics,  547,  558 
table    of   organs    secondarily 

afl'ected,  549 
tables,  553,  557,  562,  568 
treatment,  666 
resume  of,  573 
uterine,  cancer,  fasiculated,  539.    (See 
Sakcoma  of  the  utekus.) 
cysto-fibromata,   523.      (See    Ttr- 

MOKS,  FIBRO-CYSTIC.) 

fibro-cystic,  523 
course,  529 
definiti<ni,  523 
difterentiation,  526 
duration,  529 
frequency,  523 
pathology,  624 
physical  signs,  626 
prognosis,  529 
symptoms,  526 
synonyms,  523 
termination,  529 
treatment,  529 
fibroid   or   myo-fibromata  of   the 
uterus,  499 
absorption  of,  510 
Aveling's  polyptome,  614 
causes,  503 
comi)lications,  504 
course,  507 
curative  means,  510 
cure,  modes  of,  508 
definition,  499 
deve]o]nnent,  mode,  501 
difterentiation,  606 
diseases  of,  602 
duration  of,  507 
ergot,  subcutaneous  injection 
of,  bv  Hildebraiidt's  meth- 
od, 512 
forcejis,  Nelaton's,  514 
fre(iuency,  507 
gastrotomy,  for  removal  of,518 

ablation  of  uterus,  statis- 
tics, ".20 
with,  519 

cases,  Pean's  report  of,  619 

dangers  of,  621 

Hilii<'brandt's  synopsis  of 
cases,  511 
history,  500 


798 


INDEX. 


Tumors,  uleriue,  fibroid — 
interstitial,  503 
Moleswortb's  cervical  dilator, 

513 
Nelaton's  foi'ceps,  514 
operation  for  removal,  modes 

of,  522 
pathology,  5'J;) 
physical  signs,  535 
prognosis,  5U7 
polyptome,  Aveliug's,  514 
situations  of,  501 
symptoms,  50-4 
synonyms,  499 
submucous,  503,  532 
subserous,  503 
surgical  procedures,  512 
termination,  507 
treatment,  palliative,  508 
curative,  510 
avulsion,  516 
t'crasement,  514 
enucleation,  516 
excision,  514 

hyi)odermic  injections  of 
ergot,         Hildebrandt's 
method,      synopsis      of 
cases,  511 
varieties,  51)3 
fibroid  recurrent,  539.     (See  Sar- 
coma OF  THE  rTEKUS.) 

fibro-plastic,  539.  (See  Sar- 
coma, etc.) 

fibrous  malignant,  539.  (See  Sar- 
coma, etc.) 

fibrous,  dift'erentiation  from  pelvic 
peritonitis,  477. 

myeloid,  ."iSO.  (SeeSARCOMA,etc.) 

myo-fibromata,     499.       (Sim-    Tu- 

MOKS,  UTERINE,  FIBROID.) 

sarcoma,  539 

causes,  .041 

course,  542 

definition,  540 

differentiation,  642 

duration,  542 

frequency,  540 

history,  539 

pathology,  540 

physical  signs,  542 

prognosis,  .")43 

symptoms,  542 

synonyms,  ,540 

termination,  ;"42 

treatment,  543 
sarcomn tons,  .1.39.     (See  TuMORS, 

UTERINE,  SARCOMA.) 


ULCERATION  a  cause  of  urinarv  fis- 
tula, 1S3 
CTlcers,  cancerous,  5.j3 
corroding,  5.52 
granular,  309 

alterative  applications  to,  3'.  4 
causes  exciting,  310 

predisposing,  310 
cocks-comb  granulations,  314 
congestion,  prevention  of,  ,)15 
course,  311 
definiti.m.  .309 
duration,  311 


Ulcers,  granular — 

frequency,  309 
pathology,  312 
physical  signs,  311 
jDrogno.sis,  312 
symptoms,  311 
treatment,  313 
l^hagedenic,  553 
rotlent,  552 

syphilitic,  of  the  cervix,  318 
course.  319 
dirterentiation,  319 
frecjuency,  31.S 
termination,  319 
treatment,  320 
Uretero-nterine  fistula*,  211 
Urethra;,  prolapsus,  119 

treatment,  119 
Urethral  caruncle,  irritable,  116 
causes,  117 
course,  118 
duration,  118 
dirterentiation,  118 
pathology,  116 
physical  signs,  117 
prognosis,  118 
treatment,  118 
Urethral  venous  angioma,  119 
Ureihro-vaginal  Hstulje,  179 
Uriuary  fistuhc,  1.8 

causes,  180,  181,  183 
sym])toms,  1K3 

recjuiring  s])ecial  treatment,  209 
Uteri,  cervix,  ami>utation  of,  629 

conditions  demanding,  630 
dangers,  630 
liistory,  ()29 

operations  by  bistoury,  631 
by  ccraseur,  631 
by  galvano-cautery,  632 
by  scissors,  631 
methods  of  performance, 

6.31 
varieties  of,  631 
cystic  degeneration  of,  316 
cau.ses,  317 
definition,  316 
j)athology,  316 
progncjsis,  317 
synonyms,  317 
treatment,  317 
conoidal,  a  cause  of  sterility,  626 
double  scissors  for  slitting,  414 
dry  cupi^ing,  sj'ringe  for,  616 
granular     deger^eration     of,    309. 

(See  Ulcer,  granular.) 
incision  of,  for  dysmenorrhoea,590 
Sinis's  method,  591 
instruments  for,  590,  591,  592 
cedematous  elongation  of,  337 
posterior  section  of,  in  flexions,  J]3 
removal  of,  in  areolar  hy|)ciplasia, 
bv  galvano-cautery, 
308 
by  knife,  3(i8 
syphilitic  ulcer  of,  318.     (See  Ul- 
cer, SYPHILITIC,  etc.) 
Uterine    disease,    general    ctmsiderntions 
upon,  '2h) 
diagnosis,    itniii-rfect,    in, 

224 
factors,  especial,  in,  218 


INDEX. 


799 


Uterine  disease — 

general  management  and 
bygii-ne   in,  inattention 
to,  226 
prognosis  in,  222 

erroneous,  in,  225 
therapeutics,  ineflic-ieutor 

inappropriate,  225 
treatment,  reasons  for  fail- 
ure in,  224 
pathology  and  treatment,  general  con- 
siderations upon,  216 
historical  sketch  of,  30 
theories  about,  220 
cavity,  injections  into,  266 
dangers  of,  2(57 
dilator,  for  inverted  uterus,  449 
diseases,  diagnosis,  imperfect,  in,  224 
etiology  of,  43 
factors,  special,  of,  218 
general  considerations  upon,  216 
general  management  and  hygiene, 

inattention  to,  226 
prognosis  in,  222 

erroneous  in, 225 
reasons   for  failure   in  treatment 

of,  224 
theories  about,  220 
therapeutics,  inajipropriate  or  in- 
efficient in,  225 
fibroid  or  myo-fibromata,  499 

differentiation  from  inver- 
sion of  the  uterus,  430 
hydatids,     576.       (See      Hydatids, 

UTERINE.) 

irritation  in  undeveloped  ovaries,  640 

moles,  574.     (See  Moles,  uterine  ) 

pathology  and  treatment,  general  con- 
siderations on,  216 

polypi,  530.   (See  Polypi,  uterine.) 

repositor,  Sims's.  379 

scarificator,    Buttle's    spear-pointed, 
303 

sound,  as  a  means  of  physical  diag- 
nosis, 73 
Uterus,  ablation  of,  519 

absence  of,  612 

acute  intiaramatiun  of  the  lining  mem- 
brane of,  or  acute  endometritis,  229 

amputation  of  the  neck  of,  62f».     (See 
Cervixuteri,  amputation  of.) 

anatomy,  normal,  of,  324 

anteflexion  of,  402.    (See  Anteflex- 
ion OF  the  uterus.) 

arteversion  of,  357.      (See  Antever- 

SION  OF  the  uterus.) 

areolar     hyperjilnsia    of,    274.      (See 
Areolar  hyperplasia  of  the 

UTERUS.) 

ascent  of,  327 

author's    views   of   the    pathological 

states  causing  disease  of,  21H 
cancer  of,  543.   (See  Cancer  of  the 

UTERUS.) 

of    the  body    of,    564,    565.      (See 
Cancer  op  the  body  of  the 

UTERUS.) 

epithelial,  546,  549 
cancroid  of,  550 
chronic  inflammafion  of  tlie  cervical 

mucous  membrane  of  the,  or  chronic 

cervical  endometritis,  236 


Uterus — 

chi-onic  inflammation  of  the  mucous 
membrane   of  the   lnuly  of   the,   or 
chronic  corporal  end  i;;i;i  litis,  254 
conditions  necessary  for  the  healthy 

action  of  the,  217  ' 
cysto-fibromata    of,    523.      (See    Tu- 
mors, FIBRO-CYSTIC.) 
disease    of,    Bennett's    views   of,   29, 
30 
due  to  displacements,  34 
Tyler  Smith's  views  of,  32 
Velpeau's  views  of,  33 
displacements    of,    320.       (See    Dis- 
placements OF  uterus.) 
of,  general    considerations    upon, 
320 
dividing  line  between  body  and  cervix 

of  the,  223 
epithelioma  of,  546,  549 
tables,  553 
ulcerating,  552 
vegetating,  554 
fibro-cystic  tumors  of,  523 
fibroid  recurrent  tumors  of,  .539.   (See 

Sarcoma  op  the  uterus.) 
fibroid  tumors  of,  499,  532 
fibro-plastic    tumors    of,    539.      (See 

Sarcoma  of  the  uterus.) 
flexions  of  the,  390- 
fungous  degeneration  of  the  mucous 
membrane  of  the,  treatment  of,  61)9 
general    considerations  upon  the  p;i- 

thology  and  treatment  of  the,  216 
hydatids  of  the,  576 
inversion  of  the,  423 
latero-tlexion  of  the,  '122 
methods  of   exploring  the  cavity  of 
cervix  and  body,  74,  7.">,  77 
outer   surface   of   cervix  and 
body,  62,  63 
normal  position  of,  ."59 
pathology  of  infianiniation  of,  .30 
polypi  of,  530.     (See  PoLYPUS,  UTE- 
RINE.) 
probing,  method  of,  75 
prognosis  in  afi'ections  of,  222 
prola^isus  of,  328 

acute  and  sudden,  342 
amputation  of  the  cervix  for,  345, 

629,  630 
anatomy,  328 
astringents  in,  345 
causes,  330,  333,  334,  335 
clamp,  toothed,  used  in  Thomas's 
operation  for  narrowing  the  va- 
gina, 355 
complications,  341 
course,  338 
definition,  32o 
diagram,  329 
dilferentiation,  340 
dilating  force|>s  used  in  Tliomas's 
operation  for  narrowing  the  va- 
gina, •'i54 
duration,  338 
elytrnrrhaphy  for,  X50 
episiorrhaphv  for,  177,  357 
frequency,  .'!2.S 

Gneniot's  deductions  upon,  .".37 
cedematous    elongation  with  pro- 
lapse of  tlie  neck,  3o7 


800 


i:n^dex. 


TJterns,  prolnpsns  of — 

operation    for   narrowing  vagina, 
Emmet's,  o52 
Sinis's,  351 
Thomas's,  354 
pathology,  332 
perineal  sii]>p()rt  in,  3i9 
perineorrhaphy,  3i9 
pessaries,  346 
]>liysical  signs,  33!) 
jiressure  from  above,  344 
prognosis,  3i0 
rejilacing  the  uterus,  342 
suiklen  and  acute,  342 
sustaining  the  uterus,  343 
symptoms,  339 
synonyms,  328 
termination,  338 
tonics  in,  345 

trai'tion  by  vagina,  means  of  pre- 
venting, 349 
treatment,  342 

uterine      supports,      means      of 
strengthening    and    supple- 
menting, 345 
weigiifs,  means  of  diminish- 
ing, 345 
varieties,  329 
rational  signs  of  disease  of,  57 
retroliexion  of  the,  415.    (See  Retko 

FLEXION  OF  THE  UTEKUS.) 

retroversion    of    the,    373.     (See    IlE- 

TROVER.SrON  OK  THE  UTEKUS.) 

sarcoma  of  the,  539.     (See  Sakcoma 

OP  THE  UTEKUS.) 
sclerosis  of  the,  2S8 
subinvolniion  of  the,  a  cause  for  areo- 
lar liviierplasia,  285 
of  the,'2l9 

VAGINA,  atresia  of,  161 
Amnssat's  operation,  166 
causes,  162 
definition,  161 
differentiation,  1(53 
Dupnytren's  operation,  1(;6 
history,  161 
methods    of   evacuating   retained 

menstrual  blood,  165 
operation  to  render  an  obliterated 

vagina  pervious,  166 
pathology,  161 
phj'sical  signs,  163 
prognosis,  103 
results,  1()3 
s.ymptoms,  162 
synonyms,  161 
treatment,  164 
varieties,  161 
closure  of   (kolpokleisis)  for  the  re- 
lief of  vesico-vagiual  fistula,  207 
hernia  of  the,  173 
cystocele,  173 
enterocele,  175 
rectocele,  174 

support,  supplementary,  176 
surgical  procedvires,  177 
treatment,  176 
inflammation  of  the,  150.     (See  Va- 
ginitis ) 
narrowing   of   the,   Thomas's   opera- 
tion, 354 


Vagina — 

obliteration     of    the     (kolpokleisis). 

Simon's  operation  for,  208 
prolajisns  of  the,  169 

causes,  172 

complications,  173,  174 

cop.rse,  172 

definition,  169 

duration,  172 

pathology,  171 

prognosis,  173 

surgical  jirocedures,  177 

sym])toms,  173 

synonyms,  169 

termination,  172 

treatment,  176 

varieties,  172 
tapping  through  the  walls  of,  in  ova- 
rian tumors,  705,  708 
Vaginal  dei)ressor,  Sims's,  69 
dilator,  Sims's,  145 
hernia',  173.     (See  HERNIA.) 
injections  in  areolar  hyperplasia,  301 
ovariotomy,  732 

case,  Batty's,  737 
Gilmore's,  736 
Thomas's,  733 
stricture,  treatment,  593 
sup]>ositories  in  affections  of  the  cer- 
vix uteri,  315 
touch  in  physical  diiignosis,  60 
Vaginismus,  141 
anatomy,  142 
causes,  142 
course,  144 
<lefinition,  141 
difierentiation,  144 
duration,  144 
freiiuenc.v,  141 
history,  141 
oi)eralion,  Burns's,  for,  148 

Sims's,  for,  147 
pathology,  142 
l)hysical  signs,  144 
]irognosis,  144 
Scanzoni  on,  116 
sterility  caused  liy,  626 
svinjitoms,  144 
Tilt  on,  146 
treatment,  145,  149 
Vaginitis,  anatomy,  150 

definition,  :50 

prognosis,  153 

synonyms,  150 

treatment,  159 

varieties,  151 
granular,  15S 

causes,  159 

definition,  158 
•     pathology,  158 

suppositories  in,  160 

symptoms,  159 

synonyms,  158 

treatment,  159 
simple,  151 

causes,  152 

complicatious,  154 

definition,  151 

diflferentiation,  154 

pathology,  152 

physical  signs,  153 

prognosis,  153 


INDEX, 


801 


Vaginitis,  siuii)le — 

syioptoms,  153 

treat  mt^nt,  159 

varieties,  151 
speiitic,  or  gonorrhcea,  15i 

causes,  155 

CO  111  plications,  157 

course,  156 

definition,'  154 

differentiation,  155 

duration,  156 

Noeggerath  on,  156 

pathology,  154 

physical  signs,  155 

symptoms,  155 

termination,  156 

treatment,  159 
Valvular  specula,  68 

method  of  introducing,  71 
Venous  urethral  angioma,  119 
Ventral  hernia  after  ovariotomy,  763 
Versions  of  the   uterus,  anteversion,  357. 
(See    AnTK  VERSION     OF     THE 
UTEKUS.) 

retroversion,   373.      (See    IvETKO- 
VEKSION  OP  THE  UTERUS  ) 

inversion,  423.     (See  iNVEKsroN 

OF  THE  XJTEKUS.) 

patliological  significance  of,  3-2 
Vesico-rectal  exploration  in  physical  diag- 
nosis, 66 
Vesico-uteriue  fistula,  179,  209 
Vesico-utero-vaginal  fistula,  179,  21(> 
Vesico-vaginal  fistula,  179 

Bozeman's  apparatus,  734 
catheter,  sigmoid,  Sims's,  198 
causes,  ISO,  181,  183 
cauterization,  191 
closure  of  vagina  for,  207 
complications,  184 
cure,   natural,    means  of  ob- 
taining a,  191 
elytroplasty,  206 
history,  185 
kolpokleisis,  191,  208 
operation  for,  methoel  of  unit- 
ing the  edges,  204 
Gosset's,  188 
Metzler's,  189 
Simon's,  199 

advantages  of,  201,  2<;3 
Sims's,  187,  192 
paring  the  edges  of,  193 
passing  the  needle,  196 

the  sutures,  195 
physical  signs,  184 
position  of  the  patient,  2ft0, 201 
preparation  of  the  patient,  192 
prognosis,  184 
silver-wire  sutures  in,  197 
Sims  on,  184 
sutures,  192 

twisting  the,  197 
symptoms,  183 
trejitment,  191 

afterwards,  205 


Vesico-vaginal  fistula — 

vivifying  the  edges  of,  202 
Vestihule,  anatomy  of,  86,  97 
bulbs,  rupture  of  the,  97 
Viscera,    abdominal,    excessive    devel()i> 
ment    of,    ditieneutiated    from    ovarian 
tumor,  694 
Vulva,  anatomy  of,  86 
diseases  of,  86 

eruptive,  of,  95 
acne,  96 
eczema,  95 
elephantiasis,  96 
erysipelas,  96 
erythema,  96 
lichen,  95 
prurigo,  95 
syphilis,  96 
treatment,  96 
hypersesthesia  of,  114 
causes,  115 
definition,  114 
difierentiation,  115 
frequency,  115 
pathology,  115 
symptoms,  115 
treatment,  115 
Vulvae,  pruritus,  106 
causes,  lOS 
course,  107 
definition,  106 
tlevelopment,  mode  of,  107 
etiology,  108 
pathology,  106 
treatment,  110 
Vulvitis,  definition,  87 
follicular,  89 
causes,  90 
course,  91 
definition,  89 
duration,  91 
symptoms,  90 
synonyms,  89 
treatment,  91 
gangrenous,  92 
causes,  92 
definition,  92 
pathology,  92 
symptoms,  92 
synonyms,  92 
treatment,  93 
purulent,  87 
causes,  88 
course,  88 
symptoms,  88 
termination,  88 
treatment,  89 
varieties,  87 
Vulvo-vagiual  glands,  absc^ess  of,  93 
anatouiy  of,  93 
causes  of,  94 
course  of,  94 
cyst  of,  93 
duration  of,  94 
difierentiation  of,  94 
treatment  of,  94 


THE    END. 


51 


WEST  ON  CHILDREN— New  Edition —Now  Eeady. 
LECTURES  ON  THE 

DISEASES  OF  INFANCY  AID  CHILDHOOD. 

By  CHARLES  WEST,  M.D., 

Physician  to  the  Hospital  for  Sick  Children,  etc. 

Fifth  American  from  the  Sixth  Revised  and  Enlarged  English  Edition. 

Jn  one  large  and  handsome  octavo  volume  of  67S  pages  :  cloth,  $4  50  ;  leather,  $5  50. 

The  continued  demand  for  this  work  on  both  sides  of  the  Atlantic,  and  its  translation  into 
German,  French,  Italian,  Danish,  Dutch,  and  Russian,  show  that  it  fills  sati!:factorily  a  want 
extensively  felt  by  the  profession.  There  is  probably  no  man  living  who  can  speak  with  the 
authority  derived  from  a  more  extended  experience  than  Dr.  West,  and  his  work  now  pre- 
sents the  results  of  nearly  2000  recorded  cases,  and  600  post-mortem  examinatiotis,  selected 
from  among  nearly  40,000  cases  whicli  have  passed  under  his  care.  In  the  preparation  of 
the  present  edition  he  has  omitted  much  that  appeared  of  minor  importance,  in  order  to  find 
room  for  the  introduction  of  additional  matter,  and  the  volume,  while  thoroughly  revised, 
is  therefore  not  increased  materially  in  size. 


Praise  is  superfluous  where  merit  has  already 
gained  its  deserved  reward.  The  perfect  clearness 
of  the  style  of  the  author,  the  praciical  character 
of  his  instruction,  and  the  completeness  of  the 
study  of  each  di.sease,  render  the  volume  indis- 
pensable to  every  practitioner  who  is  called  upon 
to  treat  children. — Chicago  Iledioal  Examiner , 
June  15,  1S74. 

We  very  much  like  the  conservatism  which  has 
induced  him  to  retain  all  that  is  good  of  the  p;ist, 
even  though  it  he  old,  whilst  at  the  same  time  he 
utilizes  all  the  discoveries  and  improvements  of 
modern  times.  We  might  rest  the  merits  of  the 
work  ou  the  bare  fact  that  it  has  gone  through  six 
editions  in  England,  five  in  America,  and  four  in 
Germany,  besides  being  translated  in  four  other 
European  languages.— Paci/Jc  Med.  and  Surgical 
Journal,  July,  1S74. 

When  a  work  has  reached  its  sixth  edition  at 
home  and  its  fifth  abroad,  its  popularity  and  use- 
fulness cannot  be  questioned.  There  is  no  work  in 
the  English  language  more  familiar  to  the  physi- 
cian than  West  on  the  Diseases  of  Children. 
Nearly  all  have  read  it,  and,  on  the  present  occa- 
sion, it  is  only  sufficient  to  call  the  attention  of 
the  public  to  the  issue  of  a  new  edition. — Rich- 
mond and  LinUsville  Med.  Journal,  June,  1S74 

To  the  practitioner  it  will  prove  a  thoroughly  safe 
gnido,  and  a  repertory  of  extensive  and  varied 
clinical  experiences. — Chicago  Medical  .Journal, 
July,  1874. 

Of  all  writers  on  the  diseases  of  infancy  and  child 
hood  we  have  found  none  so  satisfactory  as  Dr. 
West.  The  necessary  study,  carefal  investigation, 
and  labor  to  produce  this  work  must  liave  taken 
unlimited  time,  and  in  connection  with  the  ele- 
gance of  expression  and  common  sense,  reader  it 
by  far  the  most  valuable  that  we  have  ever  had 
the  pleasure  of  consulting. — Peninsular  Journ. 
of  Mtdicine,  June,  1874. 

This  has  been  a  standard  work  and  text-book 
with  the  profession  for  more  than  a  quarter  of  a 
century.  It  still  holds  its  place,  and  comes  out  in 
another  revised  edition.  When  we  consider  the 
imi);)rtance  of  the  subject  treated  by  the  author, 
and  his  eminent  ability,  with  his  systematic 
method  of  presenting  his  subject,  we  are  at  no  loss 
to  account  for  the  great  popularity  of  his  valuable 
treatise. — Cincinnati  Lancet,  June,  1874. 


The  work,  which  has  longsince  obtained  a  well- 
deserved  reputation,  from  its  clear  description  of 
disease,  and  the  fine  style  in  which  it  is  written, 
has  now  reached  its  sixth  edition.  The  present 
work  has  been  very  carefully  revised,  and  a  good 
deal  of  new  matter  has  been  added.  Several  parts 
have  been  re- written,  and  the  work,  still  retaining 
its  original  form,  has  been  brought  d.iwu  to  the 
latest  da.te.  — London  Lancet,  May  30,  1874. 

West  is  a  capital  book  of  reference,  and  no  one 
would  think  of  discoursing  or  writing  upon  a  sub-  ■ 
ject  in  this  department  without  fortifying  himself 
with  West's  views.  It  is  the  book  of  reference, 
however,  which  is  of  most  utility  to  the  daily 
practitioner;  hence,  it  is  to  the  practitioner  rather 
than  to  the  student  that  this  book  will  commend 
itself. — Cinci^-niiti  Clinic,  June  6,  1874. 

No  medical  student  can  afford  to  be  without  this 
classical  bo  k  of  a  great  and  model  physician. 
Few  have  the  opportunities  of  Dr.  West  for  obser- 
vation, and  fewer  still  the  peculiar  powers  neces- 
sary for  successfully  studying  the  diseases  of 
children.  We  presume  that  f:>w  medical  libraries 
of  a  dozen  volumes  are  without  the  above  work. 
This  is  true,  principally,  because  it  is  indispensa- 
ble to  every  general  practitioner. — Detroit  Rev. 
of  Med.  and  Phurm..  Jane,  1S74. 

For  this  unvarying  popularity  two  reasons  are 
very  apparent.  First,  the  statements  are  based 
upon  a  multitude  of  carefully  observed  and  skil- 
fully recorded  cases,  and  so  possess  a  truthfulness 
and  an  adaptability  to  a  pliy-iti,;n'.s  wants,  that 
cannot  be  attained  by  a  work  that  results  from 
any  amount  of  familiarity  with  the  literature  of 
the  subject  only  ;  and  second,  very  few  writers  ou 
medical  topics  have  ever  succeeded  in  clothing 
their  ideas  and  statements  in  so  agreeable  a  style 
as  Dr.  West  has  at  his  command. — New  Rtrnedien, 
New  York,  July,  1874. 

A  publication  of  a  new  edition  of  Dr.  West's  e:t- 
cellent  book,  which  should  include  liis  latest  ii- 
vestigations  and  observations,  avain  places  the 
work  in  the  front  rank  of  antliorities  ou  diseases 
of  children.  The  new  edition  Ciiiiie  to  hand  too 
late  to  be  announced  in  the  annual  circul.<»rs  as 
one  of  the  text-books  of  the  Jledical  Department 
of  the  University  of  Louisiana,  Imt  wp  h-ive  au- 
thority from  Professor  Hawthoriif  t'>  advertise  it 
as  one  of  his  text-books. — N.  0.  Med.  and  Hurg 
Jotirnal,  July,  1S74. 


HENRY  C.  LEA,  Philadelphia. 


SMITH  ON  CHILDREIT.— Second  Edition.— Just  Issued. 


A  COMPLETE  PRACTICAL  TREATISE  ON  THE  DISEASES  OF  CHILDREN. 

SECOND  EDITION,  REVISED  AND  OMEATLX  ENLARGED. 


By  J.  LEWIS  SMITH,  M.  D., 

Professor  of  Morbid  Anatomy  in  the  Bellevue  Hospital  Med.  College,  N.  Y. 
In   one   handsome   octavo   volume   of  742  pages :    cloth,    $5 ;    leather,    $6. 

This  work  will  be  found  to  contain  nearly  one-third  move  matter  than  the  previous  edition, 
and  it  is  confidently  presented  as  in  every  respect  worthy  to  be  received  as  the  standard 
American  text- book  on  the  subject. 


From  the  space  ai  our  disposal,  it  would  be  im- 
pos-ible  fully  to  review  this  valuable  work,  wbich 
we  heartily  commend  to  our  reailers  as  a  practical 
and  trustworthy  guide  to  the  diseases  of  infancy 
and  childhood  ;  it  is  in  every  respect  what  the  au- 
thor represents  it  to  be,  viz.,  succinct,  yet  compre- 
hensive, and  containing  all  recently  ascertained 
facts  relating  to  this  branch  of  medical  scipnce, 
while  the  author  has  respected  the  opinions  of  pre- 
vious writers  and  adopted  them  as  far  as  appears 
to  him  correct. — Dublin  Journal  of  Med.  Science, 
April,  1S7;5. 

Dr.  Smith,  who  is  amply  qualified  for  the  task  by 
a  large  ftxporionce  and  by  methodical  habits  of 
study,  has  made  a  decided  improvement  in  his 
valuable  work.  He  has  not  only  rewritten  and 
condensed  those  parts  which  were  capable  of  im- 
provement in  this  way,  but  has  made  numerous 
additions.  His  work  is  one  of  the  very  best  now 
in  the  hands  of  the  profession,  both  for  the  student 
and  busy  practitioner. — Michigan  Univ.  Medical 
Jouru.,  Oct.  1S72. 

Among  the  multiplicity  of  works  on  the  diseases 
and  moiiilicalioDS  of  disease  peculiar  to  infancy  and 
childhood,  the  one  having  the  above  title  stands  ojit 
jirorainently  as  entitled  to  more  than  ordinary  con- 
sideration and  esteem.  No  matter  at  what  page  we 
open  it,  something  of  interest  always  strikes  the 
eye,  and  carries  the  reader  along  to  the  end  of  the 
chapter,  interested  and  instructed. — West.  Lancet, 
Aug.  1S7-2. 

A  well-constructed  exposition  of  the  present  state 
of  oar  knowledge  of  the  diseases  of  early  life,  per- 
vaded, a-i  it  should  he,  with  the  results  of  the  au- 
thor's owa  extensive  and  careful  investigations. — 
N.  T.  Mtd.  Juurn.,  Nov.  1S72. 

The  immense  clinical  material  embraced  in  the 
various  city  hospitals  of  New  York,  with  most  of 
which  Dr.  Smith  is  connected,  has  afforded  to  him 
most  excellent  opportunities  for  the  study  of  dis- 
ease. The  result  has  been,  not  so  much  a  brilliant 
record  of  new  observations  and  theories,  but  rather 
a  sound  practical  treatise. — New  Remedies,  July, 
1S72. 

Eminently  practical  as  well  as  judicious  in  its 
teachings.  —  Cincinnati  Lancet  and  Oba..  July,  '72. 

A  standard  work  that  leaves  little  to  be  desired. 
—  Indiona  Journ.  of  Med.,  July,  lb72. 

We  know  of  no  book  on  this  subject  that  we  can 
more  cordially  recommend  to  the  medical  student 
and  the  practitioner. — Cincinnati  Clinic,  June  29, 
1S72. 

We  regard  it  as  superior  to  any  other  single  work 
on  the  diseases  of  infancy  and  childhood. — Detroit 
Rev.  of  MKd.  and  Pharmacy,  Aug.  1S72. 

We  confess  to  increased  enthusiasm  in  recom- 
mending this  second  edition. — St.  Louis  Med.  and 
Surg.  Journal,  Aug.  1S72. 

tt  is  gratifying  in  looking  over  the  second  edition 
of  this  excellent  work  to  find  that  the  author  has 
conscientiously  gone  well  over  the  ground  of  his 


former  labors,  and  modified  and  improved  wher- 
ever there  was  an  opportunity,  in  ace. irdauce  with 
the  most  recent  and  most  reliable  authority  for  so 
doing.  Many  important  additions  have  been  made 
in  the  list  of  diseases,  and,  as  stated  in  the  preface, 
"many  newformulie  which  experience  has  shown 
to  be  useful  have  been  introduced  ;  portions  of  the 
text  of  a  less  practical  nature  have  been  con- 
densed ;  and  other  portions,  esppci<illy  those  re- 
l.iting  to  pathological  histology,  have  been  rewrit- 
ten to  correspond  with  recent  discoveries."  The 
diseases  incidental  to  childhood  form  a  consider- 
able part  of  the  physician's  practice.  There  is  no 
work  that  we  can  recommend  with  more  thorough 
.satisfaction  than  the  volume  before  us. — Arner. 
Journal  of  Syphilogruphy,  Oct.  1S72. 

One  is  often  asked  What  is  the  best  work  on  the 
diseases  of  children?  and  the  reply  may  be  safely 
made,  that  the  volume  here  noticed  is,  perhaps, 
the  best  single  guide  that  can  be  obtained  in  this 
country.  —  Richmond  and  L-ntisville  Medical  and 
Surgical  Journal,  July,  lb72. 

The  high  favor  with  which  the  first  edition  was 
received,  renders  unnecessary  any  formal  intro- 
duction of  this  treatise  to  our  readers.  The  present 
edition  has  been  enlarged  by  something  over  a 
hundred  pages,  nearly  twenty  additional  diseases 
being  treated  of,  and  many  new  forrauUe  included. 
Other  portions,  especially  those  relating  to  patho- 
logical histology,  have  been  rewritten  to  corres- 
pond with  recent  discoveries.  Undue  augmenta- 
tion of  the  bulk  of  the  volume  has  been  avoided 
by  condensation  of  portions  of  the  text  of  a  less 
practical  cln  racier.  As  it  is  now  presented,  the 
book  is  one  we  can  sincerely  recommend  as  both 
creditable  to  the  author,  and  more  than  usually 
(irofitable  to  the  studious  practitioner. — Chicago 
Med.  Journal,  May,  1S72. 

The  short  time  which  has  elapsed  since  our  no- 
tice of  the  first  edition  of  this  book,  and  the  favor- 
able character  of  that  notice,  make  it  unnecessary 
for  us  to  do  more  than  express  our  pleasure  at 
seeing  a  second  edition  with  additions  which  make 
the  work  much  more  nearly  complete  than  it  w.is 
at  first.  One  of  the  great  excellences  of  the  work 
is  the  rich  clinical  and  pathological  illustration  of 
disease.  The  style  of  the  author  is  clear  and  prac- 
tical, and  altogether  the  book  is  one  which  prac- 
titioners will  find  very  valuable.  We  must  again 
rofer  with  satisfaction  to  the  treatment  of  the  sub- 
ject of  diarrhcea  and  other  intestinal  diseases  in 
cLiildren. — London  Lancet,  Sept.  7,  1S72. 

The  same  careful  Inquiry  seems  to  pervade  the 
whole  work,  which  makes  it  not  only  interesting, 
but  also  exceedingly  valuable  as  a  text-book  on 
this  important  subject.  —  Canada  Lancet,  July, 
1S72. 

The  additions  and  corrections  which  have  been 
made  in  the  second  edition  leave  nothing  to  be  de- 
sired to  make  a  text-book  which  as  authority  in 
this  class  of  disease  is  second  to  none. — Buffalo 
Med.  and  Surg.  Journal,  July,  1872. 


Philadelphia:  HENEY  C.  LEA. 


HENRY     C.     LE^'S 

(late  lea  k  blanchard's) 
OF 

MEDICAL  AND  SUEGICAL  PUBLICATIONS. 

In  asking  the  attention  of  the  profession  to  the  works  advertised  in  the  following 
pages,  the  publisher  would  state  that  no  pains  are  spared  to  secure  a  continuance  of 
the  confidence  earned  for  the  publications  of  the  house  bj  their  careful  selection  and 
accuracy  and  finish  of  execution. 

The  printed  prices  are  those  at  which  books  can  generally  be  supplied  by  booksellers 
throughout  the  United  States,  who  can  readily  procure  for  their  customers  anv  works 
not  kept  in  stock.  Where  access  to  bookstores  is  not  convenient,  books  wiirbe  sent 
by  mail  post-paid  on  receipt  of  the  price,  but  no  risks  are  assumed  either  on  the 
money  or  the  books,  and  no  publications  but  my  own  are  supplied.  Gentlemen  will 
therefore  in  most  cases  find  it  more  convenient  to  deal  with  the  nearest  bookseller. 

An  Ir.LusTRATED  Catalogue,  of  64  octavo  pages,  handsomely  printed,  will  be  for- 
warded by  mail,  post-paid,  on  receipt  of  tea  cents. 

HENRY  C.  LEA. 
Nos.  700  and  708  Sansom  St.,  Philadelphia,  July,  1878. 

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with  a  circulation  extending  to  every  country  in  which  the  English  language  is  read, 
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and  gives  the  equivalent  of  three  large  octavo  volumes  for  the  comparatively  trifling 

("For  Thb  Obstetrical  Jouenal,"  see  p.  23.) 


Henry  C.  Lea's  Publications — (Am.  Journ.  Med.  Sciences). 


cost  of  Six  Dollars  per  avnum. 

The  three  periodiculs  thus  offered  are  universally  known  for  their  high  professional 
standing  in  their  several  spheres. 

THE  AMERICAN  JOURNAL  OF  THE  MEDICAL  SCIENCES, 

Edited  BY  ISAAC  HAYS,  M.D.,  and  I.  MINIS  HAYS,  M.D., 

is  published  Quarterly,  on  the  first  of  January,  April.  July,  and  October.  Each  num- 
ber contains  nearly  three  hundred  larf;e  octavo  pages,  appropriately  illustrated  wher- 
ever necessary.  It  has  now  been  issued  regularly  for  over  fifty  years,  during  the 
whole  of  which  time  it  has  been  under  the  control  of  the  present  senior  editor.  Through- 
out this  long  period,  it  has  maintained  its  position  in  the  highest  rank  of  medical  peri- 
odicals both  at  home  and  abroad,  and  has  received  the  cordial  support  of  the  entire 
profession  in  this  country.  Among  its  Collaborators  will  be  found  a  large  number  of 
the  most  distinguished  names  of  tlie  profession  in  every  section  of  the;  United  States, 
rendering  its  original  department  a  truly  national  exponent  of  Ameiican  medicine.* 

Following  this  is  the  -'Rkvikw  IIki'ai;tmkxt,"  containing  extended  and  impartial 
reviews  ot  important  new  works,  together  with  numerous  elaborate  "Analvtical  and 
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This  is  followed  by  the  "Quaktekly  Summary  of  Improvkmkxts  a.vd  Discoveries 
IN  THE  jMedical  SCIENCES,"  classified  and  arranged  under  different  heads,  presenting 
a  very  complete  digest  of  medical  progress  abroad  as  well  as  at  home. 

Thus,  (luring  the  year  1877,  the  "Journal"  furnished  to  its  subscribers  101  Original 
Communications,  i:-J5  Reviews  and  Bibliographical  Notices,  and  227  articles  in  the 
Quarterly  Summaries,  making  a  total  of  Four  Hcndhed  and  Sixtv-tmkek  articles 
illustrated  with  G4  maps  and  wood  engravings,  emanating  from  the  best  professional 
minds  in  America  and  Europe. 

That  the  efforts  thus  made  to  maintain  the  high  reputation  of  the  "Journal"  are 
successful,  is  shown  by  the  position  accorded  to  it  in  both  America  and  Europe  as  a 
leading  organ  of  medical  progress: — 


This  is  univevsally  acl<nowledged  as  the  leading 
Ameiican  .lournal,  and  has  been  conducted  by  I)r. 
Hays  alone  until  1869,  wben  his  sou  was  associated 
witli  him.  We  quite  agree  with  tlie  critic,  that  this 
journal  is  second  to  uoue  in  tlie  lansjuage,  and  cheer- 
fully accord  toil  the  first  place,  for  nowhere  shall 


The  Philadelphia  Medical  and  Physical  Journal 
issued  its  first  number  iu  1820,  and  aller  a  brilliant 
career,  was  succeeded  in  1827  by  ihe  American 
Journal  of  the  Medical  Sciences,  a  peiiodical  of 
world-wide  repuiation  ;  the  ablest  and  one  of  the 
oldest  periodicals  in  the  world — a  journal  which  has 


■we  lind  more  able  and  more  impartial  criticism,  and  j  an  unsullied  record. — Gross's  Uielory  of  American 
nowhere  such  a  repertory  of  able  original  articles    ■  Med.  Literaturn,  1876. 

Indeed,  now  that  the  ''  Brilish  and  Foreign  Medicv-  ^  ■^^  universally  acknowledged  to  be  the  leading 
Chirurgical  Review  has  terminated  Us  career,  the  i  American  medical  journal,  and,  in  our  opinion,  is 
American  Journal  stands  without  a.  nvdl.— London  ,  gecond  to  none  in  the  language  — fio*to»  Med.  and 
Med.  Times  and  Gazette,  ^ov.  '24,  \S,i.  Hurg.  Journal,  Oct.  Ib77. 

The  present  number  of  the  American  Journal  is  an  This  is  the  medical  journal  of  our  country  to  which 
exceedingly  good  one,  and  gives  every  promise  of  the  American  physician  abroad  will  point  with  the 
mainlainiug  the  well-earned  repatation  if  the  review  j  greatest  sati- faction,  as  reHecting  liie  state  of  medical 
Our  venerable  contemporary  has  our  best  wishes,  i  culture  in  his  country.  For  a  groat  many  years  it 
and  we  can  only  expre-s  the  hope  that  it  may  con-  j  bai  been  the  medium  through  which  our  ablest  wr;i- 
tinue  its  work  with  as  much  vigor  and  excellence  for  ers  have  made  known  their  discovcriog  and  observa- 
the  next  fifty  years  as  it  has  exhibited  in  the  past,  tlons  —Addre-i-tiof  L.  P.  I'andell,  M.D.,  before  lati  r- 
London  Lancet,  Nov.  24,  ls77.  |  national  Med.  Congress,  Sept.  187t>. 

And  that  it  was  specifically  included  in  the  award  of  a  medal  of  merit  to  the  Publisher  • 
in  the  Vienna  Exhibition  in  1873.  • 

The  subscription  price  of  the  '-American  Journal  of  the  Medical  Sciences"  hi- 
never  been  raised  during  its  long  career.  It  i.s  still  Five  Dollars  per  annum  ;  ;i  ai 
when  paid  for  in  advance,  the  subscriber  receives  in  addition  the  "jMedical  News  anh 
Library,"  making  in  all  about  1500  large  octavo  pages  per  annum,  free  of  postage. 

THE  MEDICAL  NEWS  AND  I.IUllAIIY  | 

is  a  monthly  periodical  of  Thirty-two  large  octavo  pages,  making   384  pages  pcry 
annum.     Its  "Library  Department"  is  devoted  to  publishing  standard  works  on  the^ 
various  branches  of  medical  science,  paged  separately,  so  that  they  can  be  detached* 
for  binding,  when  complete.     In  this  manner  subscribers  have  received,  without  ex- 
pense, such  works  as  ''Watson's  Practice,"  "West  on  Children,"  ''Malgaigne'S' 
Surgery,"  "Stokes  on  Fever,"  and  many  other  volumes  of  the  highest  reputation 
and  usefulness.     Gosselin's  "  Clinical  Lectures  on  Surgery,"  having  been  com- 
pleted in  the  number  for  June,  1878,  with  July  will  be  commenced  the  publication  of 
"Lectures  on  the  Diseases  of  the  Nervous  System,"  by  J.  M.  Charcot,  Profes.^iir 
to  the  Faculty  of  Medicine  of  Paris,  translated  from  the  French  by  (Jeorgk  Sigersh.n. 


*  Communications  are  invited  from  gentlemen  in  all  parts  of  the  country.     Elaborate  articles  lus.i  red 
by  the  Editor  are  paid  for  by  the  Publisher. 


Henry  C.  Lea's  Publications — (Am.  Journ.  Med.  Sciences).         3 

M.D.,  M.Ch.,  Lecturer  on  Biolopy,  etc.,  Catholic  Univ.  of  Ireland   [see  p.  16),  thus 
renderintr  this  date  a  valuable  and  convenient  time  to  commince  subscriptions. 

The  "News  Department"  of  the  "Medical  News  and  Library"  presents  the 
current  information  of  the  month,  with  Clinical  Lectures  and  Hospital  Gleaninsjs. 
A  new  and  attractive  feature  of  this  will  be  found  in  an  plaborate  series  of  Originai, 
American  Clinical  Lectures,  spe('ially  contributed  to  the  News  by  gentlemen  of 
the  highest  reputation  in  the  profession  throughout  the  United  .States.  The  arrange- 
ments for  this  are  not  as  yet  completed,  but  already  the  co-operation  has  been 
secured  of  the  following: — 

S.  D.  Gross.  M.D.,  Prof,  of  Surgery.  Jefferson  Med.  Coll  .  Philada. 

Austin  Flint,  M.D..  Prof.  Piin.  and  Prac.  of  Med.,  Bellevue  Hosp.  Med.  Coll.,  N.  Y. 

S.  Weir  Mitchell,  M.D..  Phys.  to  the  Infirmary  for  Nervous  Diseases,  Philada. 

T.  Gaillard  Thomas,  M.D.,  Prof.  Obstetrics.  &c..  Coll.  Phys.  and  8urg.,  N.  Y 

J.  M.  DaCosta.  M.D.,  Prof.  Prin.  and  Prac.  of  Med.,  Jeff.  Med.  Coll.,  Philada. 

Roberts  Bartiiolow,  M.D..  Prof.  'I'heory  and  Practice  of  Med.,  Med.  Coll.  of  Ohio. 

T.  G.  Richardson,  M  D.,  Prof.  Genl.  and  Clin.  Surer. ,  Univ.  of  La.,  New  Orleans. 

William  Goodell.  M.D..  Prof.  Clin.  Gynsecology,  Univ.  of  Penna. 

FoRDYCE  Barker,  M,D.,  Prof.  Clin.  Midwilery,  &c..  Bellevue  Ho=?p.  Med.  Coll  ,  N  Y 

N.  S.  Davis,  M.D.,  Prof.  Prin   and  Prac.  of  Med..  Chicago  Med.  Coll. 

L.  A.  DuHRiNG,  M.D..  Clin.  Prof,  of  Diseases  of  the  Skin,  Univ.  of  Penna. 

"I'hkophilus  Parvin.M.D.,  Prof.  Obstetrics, &c.,  Coll.  Phys.  and  Surg.,  Indianapolis. 

IjEvfis  A.  Sayre,  M.D..  Prof.  Orthoposdic  Sursr.,  &c..  Bellevue  Hosp.  Med  Coll.,  N  Y. 

W.  H.  Van  Buren,  M.D.,   Prof.  Surgery,  Bellevue  Hosp.  Med.  Coll.,  N.  Y. 

J.  P.  White,  M.D.,  Prof,  of  Obstetrics.  &c.,  Univ.  of  Buffalo. 

John  Ashhurst,  Jr.,  Ml).,  Prof,  of  Clin.  Surg.,  Univ.  of  Penna. 

D.  Warren  Brickkll,  M.D.,  Prof.  Obstetrics.  &c.,  Charity  Hosp.  Med  Coll.,  N.  0. 

William  Pepper,  M.D..  Prof.  Clin.  Medicine,  Univ.  of  Penna. 

J.  Lewis  Smith,  M.D..  Clin.  Lee.  on  Dis.  of  Chil.,  Bellevue  IIosp.  Med.  Coll.,  N.  Y. 

William  F.  Nokris,  M.D.,  Clin.  Prof,  of  Diseases  of  the  Kye,  Univ.  of  Penna. 

P.  S.  Conner,  .M.D.,  Prof,  of  Anat.  and  Clin.  Surgery,  MeJ.  Coll.  of  Oiiio,  Cin. 

'I'homas  G.  Morton,  M.  D.,  Surgeon  to  Penna.  Hospital,  Philada. 

F.  J.  BuMSTEAD,  M.D.,  late  Prof,  of  Venereal  Dis.,  Coll.  Phys.  and  Surg.,  N.  Y. 

J.  H.  Hutchinson,  M.D.,  Physician  to  Penna.  Hospital. 

F.  Peyre  Porcher,  M.D,.  Prof,  of  Mat.  .Med.  and  Clin.  Medicine,  Med.  Coll.  of  S.C. 

Christopher  Johnson,  M.D.,  Prof,  of  Surgery,  Univ.  of  Md.,  Baltimore. 

S.  W.  Gross,  M.D.,  Surg,  to  Philada.  Hospital. 

William  Thomson,  M.D.,  Lecturer  on  Ophthalmology,  Jeff.  Med.  Coll.,  Philada. 

With  contributors  such  as  these,  representing  every  portion  of  the  United  States, 
the  publisher  feels  safe  in  promising  to  the  subscriber  a  series  of  practical  lectures 
unsurpassed  in  variety,  interest,  and  value. 

As  stated  above,  the  subscription  price  of  the  "  Medical  News  and  Library"  is 
One  Dollar  per  annum  in  advance;  and  it  is  furnished  without  charge  to  ail  advance- 
paying  subscribers  to  the  "American  Journal  of  the  Medical  Sciences." 

in. 
THE  MONTflLY  ABSTRACT  OF  MEDICAL  SCIENCE 

is  issued  on  the  first  of  every  month,  each  number  containing  forty-eight  large  octavo 
pages,  thus  furnishing  in  the  course  of  the  year  about  si.x  hundred  pages.  'I'he  aim 
iiiBof  the  "  Abstract"  is  to  present — without  duplicating  the  matter  in  the  "Journal" 
and  '•  News"— a  careful  condensation  of  all  that  is  new  and  important  in  the  medical 
journalism  of  the  world,  and  all  the  prominent  professional  periodicals  of  both  hemi- 
spheres are  at  the  disposal  of  the  Editors.  'I'o  show  the  manner  in  which  this  plan 
has  been  carried  out  it  is  sufficient  to  state  that  during  the  year  1877  it  contained — 

32  Articles  on  Anntotny  nnil  Jflii/sioloff)/. 

Ji'J  "  "    Mirtrria  Mciiird  tniil  Thernpeiitirs. 

19H  "  "     Midhiur. 

149  "  ♦«     Siii-f/rrif. 

;•,»  '  "     Uli/lirifi'ril  onil  Offiiferolnf/f/, 

i)  "  "     Mt'dicut  tfufispritilcncc  and  Toxicolor/;/ — 

Imaking  in  all  .527  articles  in  a  single  year. 

The  subscription  to  the  "  Monthly  Abstract,"  free  of  postage,  is  'I'wo  Dollars 
|.4.ND  A  Half  a  year,  in  advance. 

As  stated  above,  however,  it  will  be  supplied  in  conjunction  with  the  "American 
IfouRNAL  OF  THE  Medical  Sciences"  and  the  "Medical  News  and  Library,"  making 
In  all  about  Twenty-one  Hundred  pages  per  annum,  the  whole  free  u/ postage,  for 
pix  Dollars  a  year,  in  advance. 

In  this  effort  to  bring  so  large  an  amount  of  practical  information  within  the  reach 
|)f  every  member  of  the  profession,  the  publisher  confidently  anticipates  the  friendly 


Henry  C.  Lea's  Publications — (Dictionaries). 


aid  of  all  who  are  interested  in  the  dissemination  of  sound  medical  literature.  '^He 
trusts,  especially,  that  the  subscribers  to  the  "American  Medical  Journal"  will  call 
the  attention  oF  their  acquaintances  to  tiie  advantages  thus  ottered,  and  that  he  will 
be  sustained  in  the  endeavor  to  permanently  establish  medical  periodical  literature 
on  a  footing  of  cheapness  never  heretofore  attempted. 

PEEMIUM  rOR  OBTAINING  NEW  SUBSOEIBERS  TO  THE  "JOURNAL." 

Any  gentleman  who  will  remit  the  amount  for  two  subscriptions  for  1878,  one  of 
which  must  be  for  a  vetu  niihsmber,  will  receive  as  a  premium,  tree  by  mail,  a  copy  of 
"  Browne  on  the  Use  of  the  Ophthalmoscope"  (for  advertisement  of  which  see  p. 
2'.t),  or  of  "Fox  ON  JSkin  Diseases"  (see  p.  20),  or  of  "Flint's  Essays  on  Conserva- 
tive Medicine"  (see  p.  15),  or  of  "Sturges's  Clinical  Medicine"  (see  p.  14),  or  of 
the  new  edition  of  "Swayne's  Obstetric  Aphorisms"  (see.  p.  22),  or  of  "Tanner's 
Clinical  Manual"  (see  p.  5),  or  of  "Chambers's  Restorative  Medicine"  (see  p. 
18),  or  of  "West  ox  Nervous  Disorders  of  Children  '  (see  p.  21). 

%*  Gentlemen  desiring  to  avail  themselves  of  the  advantages  thus  offered  will  do 
well  to  forward  their  subscriptions  at  an  early  day,  in  order  to  insure  the  receipt  of 
complete  sets  for  the  year  1878. 

I^°  The  safest  mode  of  remittance  is  by  bank  check  or  postal  money  order,  drawn 
to  the  order  of  the  undersigned.  Where  these  are  not  accessible,  remittances  for  the 
"Journal"  may  be  made  at  the  risk  of  the  publisher,  by  forwarding  in  registered 
letters.     Address, 

HENRY  C.  LEA,  Nos.  706  and  7(18  Sansom  St.,  Philadelpuia,  Pa. 


jyUNOLISON  [ROBLET),  M.D., 

"^  Late,  Professor  of  Institutes  of  Medicine  in  Jefferson  Medical  College,  Philadelphia. 

MEDICAL  LEXICON;  A  Dictionary  of  Medical  Science:   Con- 
taining a  concise  explanation  of  the  various  Subject?  and  Terms  of  Anatomy,  Physiologj', 
Pathology,  Hygiene,  Therapeutics.  Pharmacology,  Pharmacy,  Surgery,  Obstetrics,  Medical 
Jurisprudence,  and  Dentistry.     Notices  of  Climate  and  of  Mineral  Waters;  FormulaB  fir 
OfBcinal,  Empirical,  and  Dietetic  Preparations;  with  the  Accentuation  and  Etymology  cf 
the  Terms,  and  the  French  and  other  Synonymes;  so  as  to  constitute  a  French  a?  well  as 
English  Medical  Lexicon.     A  New  Edition.     Thoroughly  Revised,  and  very  greatly  Mod- 
ified and  Augmented.     By  Richard  J.  I^cnglison,  M.D.     In  one  very  large  and  hand- 
some royal  octavo  volume  of  over  1100  pages.     Cloth,  $6  60;  leather,  raised  bands,  $7  50. 
(Just  Issued.) 
The  object  of  the  author  from  the  outset  has  not  been  to  make  the  work  a  mere  lexicon  or 
dictionary  of  terms,  but  to  afford,  under  each,  a  condensed  view  of  its  various  m'idical  relations, 
and  thus  to  render  the  work  an  epitome  of  the  existing  condition  of  medical  science.     Starting 
with  this  view,  the  immense  demand  which  has  existed  for  the  work  has  enabled  him,  in  repeated 
revisions,  to  augment  its  completeness  and  usefulness,  until  at  length  it  has  attained  the  positicn 
of  a  recognized  and  standard  authority  wherever  the  language  is  spoken. 

Special  pains  have  been  taken  in  the  preparation  of  the  present  edition  to  maintain  this  en- 
viable reputation.  During  the  tf  n  years  which  have  elapsed  since  the  last  revision,  the  additiocs 
to  the  nomenclature  of  the  medical  sciences  have  been  greater  than  perhaps  in  any  simiLirperiod 
ofthe  past,  and  up  to  the  time  of  his  death  the  author  labored  assiduously  to  incorporate  every- 
thing requiring  the  attention  of  the  student  or  practitioner.  Since  then,  the  editor  has  been 
equally  industrious,  so  that  the  additions  to  the  vocabulary  are  more  numerous  than  in  any  pre- 
vious revision.  Especial  attention  has  been  bestowed  on  the  accentuation,  which  will  be  found 
marked  on  every  word.  The  typ->graphical  arrangement  has  been  much  imjiroved,  rendering 
reference  much  more  easy,  and  every  care  has  been  taken  with  the  mechanical  execution.  The 
work  has  been  printed  on  new  type,  "small  but  exceedingly  clear,  with  an  enlarged  page,  so  that 
the  additions  have  been  incorpoiated  with  an  increase  of  but  little  over  a  hundred  pages,  and 
the  volume  now  contains  the  matter  of  at  least  four  ordinary  octavos. 

A  book  well  known  to  our  readirs,  and  of  which  |  tory  of  technical  terms  is  .simply  a  sine  qua  non.  In  a 
every  American  oueht  to  be  proud.  When  the  learned  I  'cience  so  exten.-^ive.  and  with  such  collaterals  as  medi- 
author  of  the  work  pa.'^.'ied  away,  probably  all  of  us  (  ^ine,  it  is  as  much  a  nei^es.sity  also  to  the  practising 
feared  lest  the  book  should  not  maintain  its  place  physician.  To  meet  the  wants  of  .students  and  most 
in  the  advancing  science  whofe  terms  it  defines.  For-  physicians,  the  dictionar)-  must  be  condensed  while 
tunately,l)r.  llichard  J.  Dun?li.«on.  having  assisted  his  I  comprehensive,  and  practical  while  perspicacious.  It 
father  in  the  revision  of  sever.il  editions  of  the  work,  ;  was  because  Dun^'lison's  met  the.se  indications  that  it 
and  havinnbeen.  therefore,  trained  in  the  metlu  ds  and  !  became  at  once  the  dictionary  of  ffeueral  use  wherever 
imbued  with  the  spirit  of  the  bonk,  has  been  able  to  medicine  was  studied  in  the  English  lanKuase.  In  no 
edit  it,  not  in  the  patchwork  manner  so  dear  to  the  formerrevision  have  the  alterations  and  additions  been 
heart  of  book  editors,  so  repul.sive  to  the  taste  of  intel-  |  30  great.  More  than  sixtliou.sand  new  subjects  and  terms 
ligent  hook  readers,  but  to  edit  it  as  a  work  ofthe  kind  I  nave  been  added.  The  chief  terms  have  been  set  in  black 
should  be  edited— to  carry  it  on  steadily,  without  jar  >  letter,  while  the  derivatives  follow  in  fmall  caps;  an 
or  interruption,  alon;:  the  grooves  of  thouirht  it  has  I  arrangement  which  preatly  facilitates  reference.  We 
tr.^velled  durinjr  its  lifetime.  To  show  the  magnitude  m.ay  safely  confirm  the  hope  ventured  by  the  editor 
of  the  task  which  Dr.  Dunelison  has  assumed  and  car-  "  that  the  work,  which  possesses  for  him  a  filial  as  well 
ried  through,  it  is  only  necessary  to  stale  that  more  j  »«  an  individual  interest,  will  be  found  worthy  a  con- 
than  si.x  thousand  new  subject.s  have  been  added  in  the  I  tinuance  of  the  position  so  lone  accorded  to  it  as  a 
present  edition.— i7(i7a.  Med.  Times,  Jan.  3,  1874.  |  itandard  nuthnrity."— Cincinnati  Clinic.  Jan.  10,  1S74. 

About  the  first  bonk  purchased  by  the  medical  stu-  '  It  has  the  rare  merit  that  it  certainly  has  no  rival 
dent  is  the  Sledical  Dictionary.    The  lexicon  explana- 1  in  the  Euglish  language  for  accuracy  and  extent  of 

refereuces. — London  Medical  Oaxette. 


Henry  C.  Lea's  Publications — {Manuals). 


A 


CENTURY  op  AMEh'/rjx  MEniCTSK    ITTC.-l^Tfi.     By  Doctor.  K    IT 
Clarke,  H    J.  Bigelow,  S.  D.  Grosg,  T.  G.  Tlio.nMs,  nnd  J.  S.  Billings.     In  one  very  hand* 
some  12mo.  volume  of  about  ;i50  piiges  :  cloth.  $2  2.5.      (Just  Ready.) 
This  work  has  appeared  in  the  pages  of  the  American  Journal  of  Medical  Sciences  during  the 
year  1876.      A.^  a  detailed  account  of  the  development  o(  medical  science  in  America,  by  gentle- 
men of  the  highest  authority  in  their  re.^^pective  departments,  the  profession  will  no  doubt  wel- 
come it  in  a  form  adapted  for  preservation  and  reference. 


TJOBLYN  {RICHARD  D.),  M.  D 

A  DICTIONARY  OF  THE  TERMS  USED  IN  MEDICINE  AND 

THE  COLLATERAL  SCIENCES.     Revised,  with  numerous  additions,  by  Isaac    Hats 
M.D.,  Editor  of  the  "American  Journal  of  the  Medical  Sciences."     In  one  large  royal 
12mo.  volume  of  over  500  double-columned  pages  ;  cloth,  $1  60  ;  leather,  $2  00. 
It  is  the  best  book  of  definitions  we  have,  and  onerht  always  to  be  Hponthe  «tud9nt'«tabl9  —Bouthern 
M-yi.  nnd  Snrg.  Journal. 

■pOD  WELL  (G.  F.),  F.R.A.S..  See.. 

A  DICTIONARY  OP  SCIENCE:  Comprising  Astronomy,  Chem- 
istry, Dynamics,  Electricity.  Heat,  Hydrodynimics  Hydro.'Jtatics,  Light.  M.-ignetism, 
Mechanics,  Meteorology,  Pneumatics,  Sound,  nnd  Statics  Preceded  by  .-in  E.-<s.iy  on  the 
History  of  the  Physical  Sciences.  In  one  handsome  octavo  volume  of  694  pan-es,  and 
many  illustrations  :  cloth,  $5. 

ffEILL  {JOHN),  M.D.,    and   ~^MITH  [FRANCIS  G.),  M.D., 

Pro/,  (if  the.  In  -Hitutes  of  Medicine  in  the  Univ.  of  Penna 

AN    ANALYTICAL    COMPENDIUxAI   OF   THE    VARIOUS 

BRANCHES  OP  MEDICAL  SCIENCE  ;  for  the  Use  and  Examination  of  Students.  A 
new  edition,  revised  and  improved.  In  one  very  large  and  handsomely  printed  royal  12mo. 
volume,  of  about  one  thousand  pages,  with  374  wood  cuts,  cloth,  $4;  strongly  bouDo  in 
leather,  with  raised  bands,  $4  75. 


TJARTSHORNE  (HENRY),  M.  D., 

ProfesKor  of  Hygiene  in  the  UHiver-fiti/  of  Pennsylvania. 

A    CONSPECTUS    OF    THE    MEDICAL   SCIENCES;   containing 

H.-indbooks  on   Anatomy,   Physiology,  Chemistry,   Materia   Medica,    Practical   Medicine, 
Surgery,  and  Obstetrics.    Second  Edition,  thoroughly  revised  and  improved.     In  one  lar^e 
royai  12mo.  volume  of  more  than   1000  closely  printed  pages    with  477  illustrations  on 
wood.     Cloth,  $4  25  ;  leather,  $5  00.     {Lately  Issued.) 
We  cau  say  with  Ihe  stricles-t  truth  that  it  i.s  tli( 

be.st  work  of  the  kiud  with  which  we  areacriiiaialed 

It  embodies  iaa  couden-sed  form  all  receut  coutiibii 


tions  to  practical  inediciae,  and  is  theiefdre  useful 
io  every  busy  practitioner  throughout  our  country, 
besides  beiug  admirably  adapted  to  the  u.--e  of  stu 
dents  of  medicine.  The  book  is  faithfully  and  ably 
executed. — Charleston  Med.  Journ.,  April,  1S7.5 


denl.s.  but  to  many  others  who  may  desire  to  refresh 
their  memories  with  the  smallest  possible  expendi- 
ture of  time. — N.  Y.  Med.  Journal,  Sept.  1874. 

The  student  will  find  this  the  most  convenient  and 
useful  book  of  the  kiud  ou  which  be  can  lay  hia 
hand. — Pacific  Med  an  I  H'lrg.  Journ.,  Aug.  1S74. 

Tuis  is  the  best  book  of  its  kiud  that  we  have  ever 
examined.     It   is  an   honest,  accurate,  aud   concise 


The  work  is  intended  as  an  aid  to  the  niedical  stu-    compeud  of  medical  sciences,  as  fairly  as  possible 
dent,  and  as  such  appears  to  admirably  fulfil  its  oh-     venresenting  their  ure>ent  cuudition.     Th.  t.l,„.  "i! 


ject  by  its  excel  lent  arrangement,  the  full  compilation 
of  facts,  the  perspicuity  aud  terseness  of  language, 
ivad  the  clear  aud  instructive  illustrations  in  some 
parts  of  the  woilc — American  Journ.  of  Pharmacy, 
Philadelphia,  July,  1S74. 
The  volume  will  be  found  useful,  not  only  to  stu- 


representing  their  pre>ent  condition.  The  cbanues 
and  the  additions  have  been  so  judicious  aud  thorough 
as  to  render  it.  so  far  a:«  it  goes,  entirely  trustworthy. 
If  students  mast  have  a  conspectus,  they  will  be  wise 
to  procure  that  of  Dr  Hartshorue.— X»Wryi<  Rev.  of 
Med   and  Pliarm.,  Aug   1S74. 


T  TJDLO  W  {J.  L.),  31.  D. 
A   MANUAL   OF    EXAMINATIONS   upon   Anatomy,   Physiology, 

Surgery,  Practice  of  Medicine,  Obstetrics,  Materia  Medica,  Chemistry,  Pharmacy,  and 
Therapeutics.  To  which  is  added  a  Medical  Formulary.  Third  edition,  thoroughly  revised 
and  greatly  extended  and  enlarged.  With  370  illustrations.  In  one  handsome  royal 
12mo.  volume  of  816  large  pages,  cloth,  $3  25  ;  leather,  $3  75. 
The  arrangement  of  this  volume  in  the  form  of  question  and  answer  renders  it  especially  suit- 
j'j   able  for  the  oflSce  examination  of  students,  and  for  those  preparing  for  graduation. 


rpANNER  {THOMAS  HA  WKES),  M.  D.,  Sfc. 

A  MANUAL  OF  CLINICAL   MEDICINE  AND   PHYSICAL  DIAG- 

NOSIS.  Third  American  from  the  Second  London  Edition.  Revised  and  Enlarged  by 
Tilbury  Fox,  M.  D.,  Physician  to  the  Skin  Department  in  University  College  Hospital, 
<fcc.   In  one  neat  volume  small  ]2mo.,  ofabout  375  pages,  cloth,  $150. 

*jff*  On   page  4,  it  will  be  seen  that  this  work  is  )fFered  as  a  premium  for  procuring  new 
subscribers  to  the  "American  Jodrnal  of  the  Mkdicai  Scikncks." 


¥ 


6  Henry  C.  Lea's  Publications — {AnaComy). 

QRAY  [HENRY),  F.R.S., 

Lecturer  on  Anatomy  at  St.  George's  Hospital,  London. 

ANATOMY,  DESCRIPTIVE    AND   SURGICAL.     The  Drawings  by 

H.  V.  Carter,  M.D.,  and  Dr.  Westmacott.    The  Dissectionsjointly  by  the  Author  and  i 
Dr.   Carter.     With  an    Introduction    on    General    Anatomy   and  Development   by  T, 
Holmes,  M.A.,  Surgeon  to  St.   George's  Hospital.     A  new  American,  from  the  eighth  t 
enlargei  and  improved  London  edition.     To  which  is  added  "  LA^MIARKS,  Medical  and  : 
Sdhgical,"  by  Luther  Holden,  F.R  C.S.,  author  of  "  Human  Osteology,"  "  A  Manual  . 
of  Dissections,"  etc.     In  one  magnificent  imperial  octavo  volume  of  nearly  1070  pages, 
with  622  large  and  elaborate  engravings  on  wood.     [Nearly  Reaf/y.) 
The  author  has  endeavored  in  this  work  to  cover  a  more  extended  range  of  subjects  than  is  cm- 1 
tomary  in  the  ordinary  text-books,  by  giving  not  only  the  details  necessary  for  the  student,  bnttl^ 
bIso  the  application  of  those  details  in  the  practice  of  medicine  and  surgery,  thus  rendering  it  both  IJn 
a  guide  for  the  learner,  and  an  admirable  work  of  reference  for  the  active  practitioner.     The  en-ilg: 
gravings  form  a  special  feature  in  the  work,  many  of  them  being  the  size  of  nature,  nearly  all ' 
original,  and  having  the  names  of  the  various  parts  printed  on  the  body  of  the  cut,  in  place  of 
figures  of  reference,  with  descriptions  at  the  foot.    They  thus  form  a  complete  and  splendid  series, 
which  will  greatly  assist  the  student  in  obtaining  a  clear  idea  of  Anatomy,  and  will  also  serve  to 
refresh  the  memory  of  those  who  may  find  in  the  exigencies  of  practice  the  necessity  of  recalling  , 
the  details  of  the  dissecting  room  ;  while  combining,  as  it  does,  a  complete  Atlas  of  Anatomy,  with 
a  thorough  treatise  on  systematic,  descriptive,  and  applied  Anatomy,  the  work  will  be  found  of 
essential  use  to  all  physicians  who  receive  students  in  their  offices,  relieving  both  preceptor  and 
pupil  of  much  labor  in  laying  the  groundwork  of  a  thorough  medical  education. 

Since  the  appearance  of  the  last  American  Edition,  the  work  has  received  three  revisions  at  the 
hands  of  its  accomplished  editor,  Mr.  Holmes,  who  has  sedulou.^ly  introduced  whatever  has  seemed 
requisite  to  maintain  its  reputation  as  a  complete  and  authoritative  standard  text-book  and  work 
of  reference.  Still  further  to  increase  its  usefulness,  there  has  been  appended  to  it  the  recettti 
work  by  the  di.^stiiiguished  anatomist,  Mr.  Luther  Holden — "Landmarks,  Medical  and  Surgical" 
— which  gives  in  a  clear,  condensed,  and  systematic  way,  all  the  information  bj'  which  the  prac-f 
titioner  can  determine  from  the  external  surface  of  the  body  the  position  of  internal  parts.  Thusi 
complete,  the  work,  it  is  believed,  will  furnish  all  the  assistance  that  can  be  rendered  by  type  and* 
illustration  in  anatomical  study.  No  pains  have  been  spared  in  the  typographical  execution  ofil 
the  volume,  which  will  be  found  in  all  respects  superior  to  former  issues.  Notwithstanding  thei 
increase  of  size,  amounting  to  over  100  pages  and  57  illustrations,  it  will  be  kept,  as  heretofore, 
at  a  price  rendering  it  one  of  the  cheapest  works  ever  oflered  to  the  American  profession. 

Also  for  sale  separate — 


TTOLDEN  [LUTHER),  F.R.C.S., 

Snrgp.-in  to  St.  B  irtholomew's  and  the  Foundling  HoipHnls. 

LANDMARKS,  MEDICAL  AND  SURGICAL.    From  the  2(1  Londoni 

Ed.    In  one  handsome  volume,  royal  ]2mo.,  of  128  pages  :  cloth,  S8  cents.    {Now  Ready.) 

The  title   of  this  book  is  very  suggestive   of  its  i    seen  for  a  long  time.— J\'.    1'.  Med.  Record,  May  11, 

radical  value,  while  the  perusal  of  I  he  work  itself  I    187S. 

Verifies   the   uiost  extravagant    expectations.     The  Qf  all  the  recent  new  works  published  we  haw 

objec    of  the  author  has  been  to  coUec    in  compact  ,    ^^  hesitancy  in  declaring  this  by  far  the  most  vain-' 

tormthelandmarks  or  surface-marks  of  he  djtrerent  ^,,i^  ^^  ,^/      practitioner.     The  author  hiS  here  . 


I 

i 


partt  of  tbe  body,  aud  indicate  their  relation  to  the 
deeper-seated  parts.  The  value  of  Ihissortof  know- 
ledge to  the  phy.sician,  but  especially  to  the  surgeon 
who,  with  anatomical  eye,  can  make  the  tissues 
transparent  before  him,  is  incalculable.  The  map- 
ping out  of  the  human  body  is  one  which  is  most  in- 
structive to  the  practical  man,  and  he  is  enabled, 
after  considerable  experience,  to  liave  landmarks 
of  his  own;  but  in  the  little  work  before  ns  this 
knowledge  is  sy.stemati?.ed  iu  sucli  an  intelligible 
manner  as  to  place  it  within  the  reach  of  all.  It  is 
one  of  the  most  interesting  little  works  we  have 


given  a  series  of  landmarks  that  will  enable  one  to 
locate  with  certainty,  by  means  of  external  appear- 
ances, nearly  every  important  part  practically  con 
sidered  in  the  body.     We  would  ad  vise  every  practi-  . 
tioner  to  procure  a  copy,  and  keep  it  always  by  him.  t 
— NanhviUeJovrn.  if  Mid. and  Hurg-Yeh.  1S78. 

This  little  work  is  a  most  valuable  collection  o  'i 
plain,  simple,  ai:d  practical  hints;  it  conlaius  in  ( 
Rtruction  which  will  be  invalnable  to  the  busy  pracj^ 
tilioner  as  well  as  to  the  student  of  medicine,  ant  i 
we  heartily  commend  it  to  our  readers. — Oanadc  1 
Med.  and  Surg.  Journ.,  April,  1S7S.  J 


^MITH  [HENRY H.),  M.D.,         and     TJORNER  [  WILLIAM  E.),  M.D., 

Prof,  of  Surgery  in  the  Univ.  of  Penna. ,  <te.  Late  Prof,  of  Anatomy  in  the  Univ.  ofPenna.,  A  ' 

AN    ANATOMICAL    ATLAS,  illustrative   of  the   Structure  of  th« 

Human  Body.     In  one  volume,  large  imperial  octavo,  cloth,  with  about  six  hundred  an< 

fifty  beautiful  figures.     $4  60. 
The  plan  of  this  Atlas,  which  renders  it  so  peca-  I  the  kind  that  has  yet  appeared  ;  and  we  must  adci 
Itarly  convenient  for  the  student,  and  its  superb  ar-  |  the  very  beautiful  manner  in  which  it  is  "got  np, 
tiatic;i.l  execution,  have  been  already  pointed  out.  We  j  is  so  creditable  to  the  country  as  to  be  flattering  \i 
mast  congratulate  the  student  upon  the  completion     our  national  pride.— America?!  MedicalJoumal. 
of  this  Atlas,  as  it  is  the  most  convenient  work  of  I 

HORNER'SSPECIAL  ANATOMY  AND  HISTOLOGY.  ;  SHARPEY  AND  QUAIN'S  HUMAN  ANATOMY.     K. 

Eighth  edition,  eKtensivelv  revised  and  modified.  ^  vised,  with  Notes  and  Additions, by  Joseph  LeidI 

In  2  vols.  8vo.,  of   over  1000  pajes,  with  320  wood-  M.D.,  Professor  of  Anatomy  in  the   University" 

cuts  :  cloth.  $6  00  Pennsylvania      Complete  in  two  large  octavo  to 

HODGES'     PRACTICAL     DISSECTIONS.        Second'  nmes.  of  about  1300  pages,  with  .^11  illustrationi 

Edition,  thoroughly  revised.     In   one   neat  royal  I  cloth,  $6  00. 
12mo. volume,  half  bound, $2  00.                                  1 


Henry  C.  Lea's  Publications— (^nafomy). 


A  LLEN  [HARRISON,  M.D.), 

■^^  Pr<'Us>'-r  of  Oomparative  Anatumy  and  Physiology  in  thf.  Uiiiv  of  Fa 

A  SYSTEM  OF  HUMAN  ANATOMY:  INCLUDING  ITS  MKDICAL 

and  Surgical  Relations.    For  the  Use  of  Practitioners  and  Students  of  Medicine      With 


sought  to  give,  not  only  the  details  of  uescriptive  anatomy  inn  clear  nnd  condensed  form  but -is,! 
the  practical  applications  of  the  science  to  medicine  and  surgery.  The  work  thus  h'.^cl'  ims  u  n 
the  attention  of  thegeneral  practitioner,  as  well  as  of  the  student,  enubling  him  not  only  t<  le 
fresh  his  recollections  of  the  dissec.ing  room,  but  also  to  recgnize  the  significance  of  all  viria" 
tions  from  normal  conditions.  The  marked  utility  of  the  object  thus  sought  by  the  author  is 
self-evident,  and  his  long  experience  and  assiduous  devotion  to  its  thorough  development  'ire  a 
sufficient  guiinintee  ot  the  manner  in  which  his  aims  have  been  carried  out.  No  pains  hive'been 
spared  with  the  illustrations.  Those  of  normal  anatomy  are  from  original  dissections  drawn  on 
Stone  by  Mr.  Hermann  Faber,  with  the  name  of  every  part  clearly  engraved  upon  the  fiiiure 
after  the  manner  of  "Holden"  and  "Gray"  and  in  every  typographical  detail  it  will  be  the 
effort  of  the  publisher  to  render  the  volume  worthy  of  the  very  distinguished  position  which  is 
anticipated  for  it.  " 

lYILSON  [ERASMUS),  F.R^. 

A  SYSTEM  OF  HUMAN  ANATOMY,  General  and  Special.    Edited 

by  W.  H.  aoBRECHT,  M.  D.,  Professor  of  General  and  Surgic;il  Anatomy  in  the  Medical  Col 
lege  of  Ohio.  Illustrated  with  three  hundred  and  ninety-seven  engravings  on  wood  J 
one  large  and  handsome  octavo  volume,  of  over  600  large  pages  ;  cloth,  ^,4  j    leather  ib 

ZJEATH  [CHRISTOPHER),  F.  R.  C.S., 

*-*•  Teacher  of  Operative  Surgery  in  University  College,  London. 

PKACTICAL   ANATOMY:    A   Manual   of  Dissections. 


leather,  $4  00 
"In  presenting  this  American  edition  >f' Heath's 
ractical  Anatomy,'  I  feel  that  I  have  leeu  In- 
'trumental  in  supplying  a  want  long  felt  for  a 
eal  dis!~ector"g  tnanual,"  and  this  as-'-ertion  of  Us 
iitor  we  deem  is  fully  justified,  after  an  examina- 
on  of  its  contents,  for  it  is  really  an  excellent  work. 


HOD 

be 

the  I 


of  the  subject  and  -v. ^•icaUelected  matter         ""'** 
-  St.  Louts  Med.  a7iU  Surg.Journul,  ilar.  10,'l871  ' 


'DEL  LAM  Y{E.),F.  R.  G.S. 

THE  STUDENT'S  GUIDE  TO  SURGICAL  ANATOMY;  A  Text- 

Book  for  Students  preparing  for  their  Pass  Examination.     With  engravings  on  wood 
one  handsome  royal  12mo.  volume.     Cloth,  $2  25.     {Lately  Published.)  ' 

We  welcdiue  air.  Bellamy  s  work,  as  acoutrlbu-  I  clea  r  and  concise  Btyle,  and  its  practicMl  sue       H 
on  to  the  study  of  regional  anatomy,  of  equal  value     idd  largely  to  the  interest  attachiut  toils  tp^T   •"i' 
1  the  student  and  the  surgeon.     It  is  written  in  a  |  letaiU  —i'Mcago  Mtd.  Bxavi.intr,}\a,\c\x  1    \hll 

^LELAND  {JOHN),  M.D., 

-^  Professor  of  Anatomy  and  Phy-'siology  in  Queen's  College,  Galway. 

A   DIRECTORY    FOR  THE    DISSECTION  OF  THE    HUMAN   BODY 

In  one  small  volume,  royal  12mo.  of  182  pages:  cloth,  $1  25.      (Just  Issued.) 
This  is  a  plain,  convenient,  dissecting  guide,  to  lie     in  cuniiu   n  I'se.  but  ineroly 
sed  over  the  subject.     As  such,  it  will  coininond  it 
If  to  the  student  by  the  lucid  composition  and  dis- 
act   directions   of   the  author.— Jl/ed.   and.  Surg. 

eporter,  Feb.  1877.  ,     .. 

This  volume  does  not  interfere  with  tbe  text-books    ^-  ^-  ^td.  Juurn.,  March,  1677 


^CHAFER  [EDWARD  ALBERT),  M.D., 

'  A/tsistant  Profe.'sor  of  Physiology  in  Cniversity  College,  London. 

A  COURSE  OF  PRACTICAL  HISTOLOGY:  Being  an  Introduction  to 

the  Use  of  the  Microscope.     In  one  handsome  royal  12mo.  volume  of  304  pages,  with 
numerous  illustrations:  cloth,  $2  00.     (Just  Issued.) 

We  are  very  much  pleased  with  the   liook.  wliicli  i   he  has  said   his  say.     The   book   has  aUo  th«  Riil 

aches  the  stiidout  .simply  how  to  use  bis  inslriinient.s  '   "•"—  ....-..".....-  ^.^.i.  ...•  ■ 

d  conduct  his  studies  without  going  furtticr  into  the 
icroseopic  anatomy  of  the  tissues  and  o^^'ans  than  is 
soluteiy  necessary.  What  we  particularly  praise  in 
is  the  way  in  which  it  takes  tbe  student  by  the  band, 
it  were,  showing  him  what  to  do,  and  explaininp 
hply,  but  thorouKhly.  how  to  do  it.— Host  n  Med.  attU 
irg.  Journ.,  April,  1S77. 

is  a  whole,  the   book  is  an  admirable  one.    The 
scriptions  are  brief,  but  they  are  clear  and  delail- 
The  author  has  learned  theartof  slopping  when  I 


more  nucominon  merit  of  bearlug  everywhere  i  i« 
impress  of  the  aulhorH  own  Ibougbt.  There  i»  no 
such  thing  In  the  book  us  it  condeusuliou  of  acliiin 
ter,  or  section  or  paiiigr.iph  Ironi  any  one  eUe  l-»-.'n 
when  rioscribiugs.nu.  of  the  commooes.  proce;^,:»  |.„ 
BhoWB^uchft  piacliCKl  fHniniHMly  wllb  Cbe  detai Ik 
as  to  give  bis  description  I  lie  ll.iviir  of  orlgiuaiiiv  In 
couchisioD.weciiu  couddeutly  recomui-ud  lh«  work 
as  the  most  useful  manual  for  tbe  praclic»l  hisiol 
gist  with  wbicb  wo  are  »c,,uainted.-CAjcai7y  jt'u 
Journ.  and  Exam.,  tSept.  l37".  "    •"*"• 


8  Henry  C.  Lea's  Publications — (Physiology). 

ftARPENTER  (  WILLIAM  B.),  M.D.,  F.B.  S.„F.G.S.,  F.L.S., 

'-^  Registrar  to  University  of  London,  etc. 

PRINCIPLES  OF  HUMAN  PHYSIOLOGY;  Edited  by  Henry  Power, 

M.B.  Lond.,   F.R.C.S.,  Examiner  in  Natural  Sciences,  University  of  Oxford.     Anew 
American  from  the  Eighthi  Revised  and  Enlarged  English  Edition,  with  Notes  and  Adiii- 
tions,  hy  Francis  G.  Smith,  M.  D.,  Professor  ofthe  Institutes  of  Medicine  in  the  Univer- 
sity of  Pennsylvania,  etc.    In  one  very  large  and  handsome  octavo  volume,  ot  UlS:.  pages, 
with  tT<  opiates  and  373  engravings  on  wood;  cloth,  $5  60;  leather,  $6  50.      {Jnst  Issued.) 
The  great  work,  the  crowning  labor  of  the  distinguished  author,  and  through  which  so  many  J 
generations  of  students  have  acquired  their  knowledge  of  Physiology,  has  been  almost  metnmor- 1 
phosed  in  the  effort  to  ar'.ipt  it  thoroughly  to  the  requirements  of  modern  science.     Since  the 
appearance  of  the  last  American  edition,  it  has  had  several  revisions  at  the  experienced  hand  of 
Mr.  Power,  who  has  modified  and  enlarged  it  so  as  to  introduce  all  that  is  important  in  the 
investigations  and  discoveries  of  England,  France,  and  Germany,  resulting  in  an  enlargement  of 
about  one-fourth  in  the  text.     The  series  of  illustrations  has  undergone  a  like  revision,  a  large 
proportion  of  the  former  ones  having  been  rejected,  and  the  total  number  increased  to  nearly 
four  hundred.     The  thorough  revision  which  the  work  ha.s  so  recently  received  in  England,  hag 
rendered  unnecessary  any  elaborate  additions  in  this  country,  but  the  American  Editor,  Pro- 
fessor Smith,  has  introduced  such  matters  as  his  long  experience  has  shown  him  to  he  requisite 
for  the  student.     Every  care  has  been  taken  with  the  typographical  execution,  and  the  work  is 
presented,  with  its  thousand  closely,  but  clearly  printed  pages,  as  emphatically  the  text-book  for 
the  student  and  practitioner  of  medicine — the  one  in  which,  as  heretofore,  especial  care  is  directed 
to  show  the  applications  of  phytiology  in  the  various  practical  branches  of  medical  science. 
Notwithstanding  its  very  great  enlargement,  the  price  has  notbe«n  increased,  rendering  this 
one  of  the  cheapest  works  now  before  the  profession. 
We  have  been  agreeably  surprised  to  find  the  vol-   t  ffctly  eertiiin  of  the  fulneFS  of  information  it  will  conJ 


ume  so  complete  in  regard  to  the  structure  aud  fu ac- 
tions of  the  uervous  sy>tein  ia  all  it.s  i-elatious,  a 
subject  that,  in  many  respecLs,  is  oueof  the  most  diffi- 
cult of  all,  in  thrt  whule  range  of  physiology,  upon 
which  to  produce  a  full  and  satisfactory  treati.'<e  of 
the  class  to  which  the  one  before  us  belongs.  The 
additions  by  the  American  editor  give  to  the  work  as 
it  is  a  considerable  value  beyond  that  i>f  th?  last 
English  ediiion.  In  eouclusion,  we  can  give  oar  cor- 
dial recommendatioa  to  the  work  as  It  now  appears. 
The  editors  have,  with  their  addition.?  to  the  only 
work  on  physiology  in  our  language  that,  in  the  full- 
est sen^e  of  the  word,  is  the  production  of  a  philo.so- 
pher  as  well  as  a  physiologist,  brought  it  up  as  fully 
as  could  be  expected,  if  not  desired,  to  the  standard 
of  our  knowledge  of  its  subject  at  the  present  day. 
It  will  deservedly  maintain  the  place  it  ha.s  always 
had  iu  the  favor  of  the  medical  profession. — Journ. 
of  Nervous  and  Mental  Disease,  April,  1S77. 

"  Good  wine  needs  no  bush"  «ays  the  proverb,  and 
an  old  and  faithful  servant  like  the  •'  big"  Carpenter,  as 
carefully  brought  down  as  thi.s  edition  has  been  by  Mr. 
Henry  Power,  needs  little  or  no  commendation  by  us. 
Such  enormous  advances  have  recently  been  madeiu  our 
phy.siological  knowledge,  that  what  wa.s  perfectly  new  a 
year  or  two  ago,  looks  now  as  if  it  had  l)een  a  received 
and  established  fact  for  years.  In  this  encyclopaedic 
way  it  is  unrivalled.  Here,  as  it  seeuis  to  us,  is  the 
great  value  of  the  book:  one  is  safe  in  sending  a  student 
to  it  for  information  on  almost  any  given  subject,  per- 


■ey.  and  well  satisfied  of  the  accuracy  with  which  it  will, 
th'Te  be  found  stated. — London  Mva.  Times  and  Gazcttei 
Feb.  17,  1876. 

Thusfullyare  treated  the  structureand  functions  of  allj 
the  important  organs  of  the  body,  while  there  are  chap- 
ters ou  sleep  aadsumuaiubulism;  chaplersou  elhuology  ;| 
a  full  section  ou  generaiiou,  and  abuudaul  references  tc 
the  curio.siiies  of  physiology,  as  the  evolutinu  of  light,! 
heat,  electricity,  etc.     In  short,  this  new  edition  of  Car- 
penter is,  as  we  have  said  at  the  start,  a  very  encyclo- 
pedia of  modern  phj'siology. — The  Clinic,  I'eb.  24, 1S77. 

The  merits  of  "  Carpenter's  Physiology  arc  so  widely 
known  aud  appreciated  that  we  need  only  allude  briefly 
to  the  fact  that  in  the  latest  edi'ion  will  be  found  a  com- 
prehensive embodiment  of  the  results  of  recent  physio- 
Io.;ie:il  investigation.  Care  has  been  taken  to  preserve 
the  practical  character  of  the  original  work.  In  fact 
the  entire  work  lias  been  brought  up  to  date,  and  bears 
evidence  of  the  amount  of  labor  that  has  been  bestowed 
upon  it  by  its  rlistinguishcd  editor,  Mr  Ilsnry  Power. 
The  American  editor  has  made  the  latest  additions,  in 
order  fully  to  cover  the  time  that  has  elapsed  since  the 
last  English  edition. — N.  Y.  Med.  Journal,  Jan.  1877. 

K  more  thorough  work  on  physiology  could  not  be 
found.  In  this  all  the  facts  discovered  by  the  late  re-  i 
searches  are  noticed,  and  neither  student  nor  practi-  ; 
tioner  should  bo  without  this  e.xhaustive  treatise  on  a.%  j 
important  elementary  branch  of  medicine. — Atlanta  ', 
iled.  and  Surg.  Journal,  Dec.  lS7t5. 


^IRKES  (  WILLIAM  SENHO  USE),  M.  D.  3 

A  MANUAL  OF  PHYSIOLOGY.     Edited  hy  W.  Morrant  BakerJJ/)^ 

M.D.,  F.R.C.S.      A  new  American  from  the  eighth  and  improved  London  edition.     With' 
about  two  hundred  and  fifty  illustrations.     In  one  large  and  handsome  royal  12mo.  vol- 
ume.    Cloth,  $3  25;  leather,  $.'J  75.      (Lately  Issued.) 
Kirkes'  Physiology  has  long  been  known  as  a  concise  and  exceedingly  convenient  text-book, 
presenting  within  a  narrow  compass  nil  that  is  important  for  the  student.     The  rapidity  wit] 
which  successive  editions  have  followed  each  other  in  England  has  enabled  the  editor  to  keep  i 
thoroughly  on  a  level  with  the  changes  and  new  discoveries  made  in  the  science,  and  the  eightl. 
edition,  of  which  the  present  is  a  reprint,  has  appeared  so  recently  that  it  may  be  regarded  a^ 
the  latest  accessible  exposition  of  the  subject 

the   hands  of  studpnts. — Bo/iton   Med.   and  Surgr, 
Journ.,  April  10,  1S7.3. 

In  its  enlarged  form  it  is,  in  our  opinion,  still  th^ 
best  book  on  physiology,  most  useful  to  the  studentgjj 
—Ptiiln.  Med.  Times,  Aug.  30,  1873 

This  is  undoubtedly  the  best  work  for  students  ol  j^Tj;, 
physiology  extant. — Cincinnati  Med.  News,  Sept.  '73)     w 


On  the  whole,  there  is  very  little  in  the  book 
which  either  the  student  or  practitioner  will  not  find 
of  practical  value  and  consistent  with  our  present 
knowledge  of  this  rapidly  changing  science  ;  and  we 
have  no  hesitation  in  expretsing  our  opinion  that 
this  eighth  edition  is  one  of  the  best  handbooks  on 
physiology  which  we  have  in  our  language. — N.  Y. 
Jfed.  Record,  April  1.5,  1S73. 

The   book  is  admirably  adapted  to  be  placed  in 


fJA R  TSHORNE  ( H ENR Y) .  M.D., 

J.  J.  Professor  of  Hygiene,  etc  ,  in  the  Univ.  of 


ofPenna. 

HANDBOOK  OF   ANATOMY  AND   PHYSIOLOGY.     Second  Edi- 

tion,  revised.   In  one  ro.vall2mo.  volume,  with  220  woodcutf :  cloth,  $1  75.  (Jt 


;ond  Ed]' 

Ttist  Issued.' 


Henry  C.  Lea's  Publications — {Physiology). 


D 


ALTON  [J.  C),  M.D., 

Professor  of  Physiology  in  the  College  of  Physicians  and  Surgeons,  New  York,  &c. 

A  TREATISE  ON  HUMAN  PHYSIOLOGY.    Designed  for  the  use 

of  Students  and  Practitioners  of  Medicine.  Sixth  edition,  thoroughly  revised  and  enlarired, 
with  three  hundred  and  sixteen  illustrations  on  wood.  In  one  very  beautiful  octavo  vol- 
ume, of  over  800  pages.     Cloth,  $5  50  ;   leather,  $6  50.     iJitst  Issued.) 

From,  the  Preface  to  the  Sixth  Edition. 
In  the  present  edition  of  this  book,  while  every  part  has  received  a  careful  revision,  the  ori- 
ginal plan  of  arrangement  has  been  changed  only  so  far  as  was  necessary  for  the  introduction  of 
new  material. 

The  adilitions  and  alterations  in  the  text,  requisite  to  present  concisely  the  growth  of  positive 
physiologic.il  knowledge,  have  resulted,  in  spite  of  the  author's  earnest  efforts  at  condensation, 
in  an  increa?e  of  fully  fifty  per  cent,  in  the  matter  of  the  work.  A  chani;;e,  however,  in  the  ty- 
pographical arrangement  has  accommodated  these  additions  without  undue  enlargement  in  the 
bulk  of  the  volume. 

The  new  chemical  notation  and  nomenclature  are  introduced  into  the  present  edition,  a.s  hav- 
ing now  so  generally  taken  the  place  of  the  old,  that  no  confusion  need  result  from  the  change. 
The  centigrade  system  of  measurements  for  length,  volume,  and  weight,  is  also  adopted,  these 
measurements  being  at  present  almost  universally  employed  in  original  physiological  investiga- 
tions and  their  published  accounts.  Temperatures  are  given  in  degrees  of  the  centigrade  scale, 
usually  accompanied  by  the  corresponding  degrees  of  Fahrenheit's  scale,  inclosed  in  brackets. 
New  YoKK,  September,  1875. 

This  popular  tesl-book  on  physiology  comes  to  us  in 
its  sixth  edition  with  the  addition  of  about  fifty  per  cent. 
of  new  matter,  chiefly  iu  the  departments  of  patho- 
logical chemistry  and  the  nervous  system,  where  the 
principal  advances  have  been  realized.  With  so  tho- 
rough revision  and  additions,  that  keep  the  work  well 
up  to  the  times,  its  continued  p^ipularity  may  be  confi- 
dently predicted,  notwithstanding  the  competition  it 
may  encounter.  The  publisher's  work  is  adiiiiiubly 
done. —  SI.  Lniiis  Med.  awl  Surg.  Journ  ,  Dec.  1S75 

We  heartily  welcome  this,  the  sixth  edition  of  this 
admirable  text  book,  than  which  tliere  are  none  of  eijual 
brevity  more  valuable.  It  is  cordially  recommendecj  by 
the  Professor  of  Physiology  in  the  University  of  Louisi- 
ana, as  by  all  competent  teachers  in  the  United  States 
and  wherever  the  Knglish  language  is  read,  this  book 
has  been  appreciated.  The  present  edition,  with  its  316 
admirably  executed  illustrations,  has  been  carefully 
revised  and  very  much  enlarged,  although  its  bulk  does 
not  seem  perceptibly  increased. — New  Orleans  Medical 
and  Surgical  Joiij-nal,  March,  1876. 

The  present  edition  is  very  much  superior  to  every 
other,  not  only  in  that  it  brings  the  subject  up  to  the 
times,  but  that  it  d'  e^  so  more  fully  and  satisfactorily 
than  any  previousedition.  Takcit  altogether,  it  remains 
in  our  humble  opinion,  the  best  text  book  on  phj-siology 
in  any  land  or  language — Tlin  Cli»ir.  \ot.  6,  187,5. 
As  a  whole,  we  cordially  recommend  the  work  as  a 

text-book  for  the  student,  ami   as   one  of  the  best. 

The  Jntirnal  nf  Nervous  and  Mental  Disease,  Jan.  1876. 

Still  holds  its  position  as  a  masterpiece  of  lucid  writ- 
ing, and  i.s,  we  believe,  on  the  whole,  the  liest  book  to 
place  in  the  hands  of  the  student. —  London  Sluilents' 
Journal. 


During  the  past  few  years  several  new  works  on  phy- 
siology, and  new  editions  of  old  works,  have  appeared, 
competing  for  the  favor  of.the  medical  student,  but  none 
will  rival  this  new  edition  of  Dalton.  As  now  enlarged, 
t  will  he  found  also  to  be.  in  general,  a  satisfactory  work 
f  reference  for  the  practitioner. — Chicago  Med.  Journ. 
nd  Examiner,  Jan.  1876. 

Prof.  Dalton  has  discussed  conflicting  theories  and 
onclusions  regarding  physiological  questions  with  a 
airness,  a  fulness,  and  a  conciseness  which  lend  fresh- 
ess  and  vigor  to  the  entire  book.  But  his  discussions 
ave  been  so  guarded  by  a  refusal  of  admission  to  those 
peculativeand  theoretical  explanation.",  which  at  best 
xist  in  the  minds  of  observers  themselves  as  only  pro- 
abilities,  that  none  of  his  readers  need  be  led  into 
rave  errors  while  making  them  a  study. — The  Medical 
^ecord,  Feb.  19,  1876. 
The  revision  of  this  great  work  has  brought  it  forward 
ith  the  physiological  advances  of  the  day.  and  renders 
t,  as  it  has  ever  been,  the  finest  work  for  students  ex- 
nt. — Nashville  Journ.  nf  Med.  and  Surg.,  Jan.  1876. 
For  clearness  and  perspicuity,  Daltou's  Physiology 
ommended  itself  to  the  student  years  ago.  and  was  a 
leasant  relief  from  the  verbose  productions  which  it 
upplanted.  Physiolocry  has,  however,  made  many  ad- 
ances  since  then  — and  while  the  style  has  been  pre- 
rved  intact,  the  work  in  the  present  edition  has  been 
rought  upfully  abreast  of  the  times.  The  new  chemical 
otation  and  nomenclature  have  also  been  introduced 
ito  the  present  edition.  Notwithstanding  the  multi- 
icity  of  text-books  on  physiology,  this  will  lose  none 
'  its  old  time  popularity.  The  mechanical  execution 
'  the  work  is  all  that  could  be  desired. — Peninsular 
mrnal  of  Medicine,  Dec.  1875. 


D 


UNGLISON  [ROBLEY),  M.D., 

Professor  of  Institutes  of  Medicine  in  Jefferson  Medical  College,  Philadelphia. 

HUMAN  PHYSIOLOGY.     Eiglith  edition.    Thoroughly  revised  and 

extensively  modified  and  enlarged,  with  five  hundred  and  thirty-two  illustrations.  In  two 
large  and  handsomely  printed  octavo  volumes  of  about  1500  pages,  cloth,  $7  00. 

r  EHMANN  (C.   O.). 

'  PHYSIOLOGICAL  CHEMISTRY.  Translated  from  the  second  edi- 
tion by  George  E.  Day,  M.  D.,  F.  R.  S.,  Ac,  edited  by  R.  E.  Rogkrs,  M.  D.,  Professor  of 
Chemistry  in  the  Medical  Department  of  the  University  of  Pennsylvani.i,  with  illustrnf  ion/» 
selected  from  Funke's  Atlas  of  Physiological  Chemistry,  and  an  Appendix  of  plates.  Com- 
plete in  two  large  and  handsome  octavo  volumes,  containing  1200  pages,  with  nearly  two 
hundred  illustrations,  cloth,  $6  00. 

r  THE  SAME  AUTHOR. 

MANUAL  OF  CHEMICAL  PHYSIOLOGY.     Translated  from  the 

German,  with  Notes  and  Additions,  by  J  Chbston  Morris,  M.  D.,  with  an  Introductory 
Essay  on  Vital  Force,  by  Professor  Samubl  Jackson,  M.  D.,  of  the  University  of  Pennsjl- 
vania,  With  illustrations  on  wood.  In  one  very  hacdsome  octavo  volume  of  3.3fi  pagee, 
oloth,  $2  25. 


10 


Henry  C.  Lea's  Publications — (^Chemistry). 


ATTFIELD  [JOHN),  Ph.D., 

Professor  of  Practical  Ohemistry  to  the  Pharmaceutical  Society  of  Oreat  Britain,  &e. 

CHEMISTRY,   GENERAL,  MEDICAL,  AND   PHARMACEUTICAL  ; 

including  the  Chemistry  of  the  U.  S.  Pharmacopoeia.     A  Manual  of  the  General  Principles 
of  the  Science,  and  their  Application  to  Medicine  and  Pharmacy.      Seventh  American  edi- 
tion, reviset  from  the  Si.xth  English  edition  by  the  author.     In  one  handsome  royal  12mo. 
volume  of  668  pages,  with  87  illustrations  :  cloth,  $2  75  ;   leather,  $3  25       {.Just.  Issued.)  . 
This  work  has  received  a  very  careful  revision  at  the  hnnds  of  the  author,  result  in  gin  a  conside- 
rable increase  in  size,  tr>gether  with  the  addition  of  a  handsome  series  of  illustrations      Notwith- 
standing these  improvements,  the  price  has  been  maintained  at  the  former  very  moderate  rate. 


It  is  a  valuable  work  for  the  busy  practitioner,  ex- 
cludiug  as  it  does  everytliin^  tbat  w,inlJ  be  of  late- 
rest  only  to  the  scientific  chetiiist,  and  baving  a  cora- 
))reliensive  index  wliicb  renders  afier  consuliation 
easy.  Tliat  portion  devoted  to  urinalysis  and  prac- 
tical toxicology,  and  ttie  tests  for  impurities  in  medi- 
cinal prep;irii(ioQ.»,  is  especially  valuable  to  the 
prac'isiui;  physician.  For  the  .sludent  it  is  desirable, 
lor  the  reason  tbat  it  is  so  arranged  that  be  may, 
without  au  instnic^or,  study  the  science  experiment- 
ally.— Am.  I'ractilioner,  March,  1877. 

AftT  bavins  used  it  a."  a  text-book  in  the  laboratory 
of  tlie  l'liiladelpbiaC<dleiiBof  I'barmacy  duriiii;  the  last 
five  year.s,  we  can  speak  from  our  own  experience,  and 
testify  to  its  intrinsic  value  in  the  instruction  of  the 
student.  The  more  we  have  used  it,  the  more  we  were 
pleased  with  it,  and  on  the  appearance  of  a  new,  revised, 
and  enlariied  edition,  we  take  occasion  to  a^ain  cordi- 
ally recommend  it,  helievins  that  for  the  practical  in- 
struction of  pharmaceutical  students  in  cheniistrj  it 
hn-i  no  superinr  in  the  Enjjlish  language. — Am.  Journ. 
of  Pliarm..  Nov.  1876. 

The  bonk,  by  a  well  arranpted  system,  introduces  the 
student  into  ihe  Science  of  Chemistry,  'Jiivim;  him  at 
each  >tep  sufficient  information  to  enable  liiin  to  per- 
form exoeriments  with  his  own  bands;  theexperiments 
are  partly  of  synthetical  and  i)artly  of  analytical  inte- 
rest: in  this  way  the  editor  succeeds  admirably  in 
avoidinj;  a  dry  monotonous  enumeration  of  facts.    The 


variety  which  he  gives  is  certainly  well  calculated  to 
prevent  the  reader  from  gcttinir  tired.  This  variety, 
hfwever.  is  not  such  as  to  bewilder  the  mind,  nor  are 
ihe  experiments  described  calculated  only  to  serve  lis  a 
pleasant  pastime.  The  student  who  reads  the  book  imd 
executes  the  experiments  mentioned,  cannot  help  but 
feel  deeply  iiterested  in  the  subject,  and  indeed,  will, 
^oinit  fhrouiih  the  practical  work,  find  it  a  very  ajree- 
able  recreation. — Cincinnati  Clinic,  (let  28.  1ST6. 

It  brinps  up  our  knowledce  of  the  subject  to  the  pre- 
sent date,  and  has  been  enriched  with  numerous  wood 
eniiraviii^sillu-^trative  of  apparatus  and  modes  of  work. 
I'he  arrangement  of  the  work  is  admirable,  and  to  each 
element  its  more  iuii)ortant  compounds  used  in  medi- 
cine or  pharmacy  are  t!iven,  together  with  both  syntheti- 
cal tind  analytical  reactions.  The  systematic  analysis 
of  compounds,  substances  or  fluids  is  also  treated  of, 
and  copious  tables  are  given  ehowiuK  the  modes  of  sys- 
tematically seimratins;  the  different  elements  from  one 
another. —  Canada  Med.  and  Surg.  Journ  ,  Nov.  1870. 

As  a  compact  manual  of  the  general  principles  of  the 
science  and  their  applications  in  medicine  and  phar- 
macy it  has  no  rival,  and  the  froi(uent  and  thorou'..'h 
revision  it  receives  keeps  it  in  all  respects  up  with  the 
times  The  American  edition,  whi<'h  covers  the  United 
.States  I'barmacopceia.  is  preparer!  under  the  author's 
supervision — limton  Journal  of  Chemistri/.  Nov.  1870. 

Admirably  a  ia-ited  to  the  use  of  medical  students.— 
Atlanta  Ated.  Journ., Oct.  1376. 


J^OWNES  [GEORGE),  Ph.D. 


A  MANUAL  OF  ELEMENTARY  CHEMISTRY;  Theoretical  and 

Practical.     Revised  and  corrected  by  IIknry  Watt.s,  B.A.,  F  R.S.,  authorof '■  A  Diction- 
ary of  Chemistry,"  etc.     With  a  colored  plate,  and  one  hundred  and  seventy-seven  illus- 
trations.    A  new  American,  from  thi  twelfth  and  enlarged  London  edition.     Edited  by 
Robert  Bridge.s,    M.D.        In    one   larpe   royal    12mo.   volume,   of  over   1000    pages; 
cloth,  $2  75  ;   leather,  $.3  25.     (Now  Ready.) 
Two  careful  revisions  by  Mr.   AV.ntts,  since  the  appearance  of  the  last  American  edition  of 
"Fownes,"  have  so  enlarged  the  work  that  in  England  it  has  been  divided  into  two  volumes.     In 
reprinting  it,  by  the  use  of  a  sina'l  and  exceedingly  cle.ar  type,  cast  for  the  purpose,  it  has  been 
found  possible  to  comprise  the  whole,  without  omission,  in  one  volume,  not  unhandy  for  study  and 
reference.    The  enlargement  of  the  work  has  induced  the  American  Editor  to  confine  his  additions 
to  the  narrowest  compass,  and  he  has  accordingly  inserted  only  such  discoveries  as  have  been  an- 
nounced since  the  very  recent  appearance  of  the  work  in  England,  and  has  addet?  the  standards 
in  popular  use  to  the  Decimal  and  Centigrade  systems  employed  in  the  original. 

Among  the  additions  to  this  edition  will  be  found  a  very  handsome  colored  plate,  representing 
a  number  of  spectra  in  the  spectroscope.  Every  care  has  been  taken  in  the  typographical  execu- 
tion to  render  the  volume  worthy  in  every  respect  of  its  high  reputation  and  extended  use,  and 
though  it  has  been  enlarged  by  more  than  one  hundred  and  fifty  pages,  its  very  moderate  price 
will  still  maintain  it  as  one  of  the  cheapest  volumes  accessible  to  the  chemical  student. 


jyOWMAN  [JOHN  E.),M.  D. 

PRACTICAL  HANDBOOK  OF  MEDICAL  CHEMISTRY.    Edited 

by  C.  L.  Bloxam,  Professor  of  Practical  Chemistry  in  King's  College,  London.      Sixth 
American,  from  the  fourth  and  revised  English  Edition.     In  one  neat  volume,  royal  12mo., 
pp.  351,  with  numerous  illustrations:  cloth,  §2  25. 
JOY  THE  SAME  AUTHOR.    (Latdy  Is-ined.)       

INTRODUCTION   TO   PRACTICAL  CHEMISTRY,  INCLUDING 

ANALYSIS.     Sixth  American,  from  the'sixth  and  revised  London  edition.    With  numer- 
ous illustrations.     In  one  neat  vol.,  royal  I2mo.,  cloth,  $2  25. 


KNAPP'S  TECHNOLOGY  ;  or  Chemistry  Applied  to 
the  .4.rt8,  aud  to  Mannfactnres.  With  American 
additions  by  Prof.  AV.41,ter  R.  Johnson.     In  two 


very  handsome  octavo  volumes,  with  .100   wood 
engravings,  doth,  $6  00. 


Henry  C.  Lea's  Publications — (Chemistry). 


11 


J?LOXAM  [C.L.), 

' "^  Professor  of  Chemintry  in  King''s  College,  London. 

CHEMISTRY,  INORGANIC  AND  ORGANIC.     From  the  Second  Lon- 

don  Edition.  In  one  very  handsome  octavo  volume,  of  700  pages,  with  about  300  illustra- 
tions. Cloth,  $4  00;  leather,  $5  00.  (Just  Issued.) 
It  has  been  the  author's  endeavor  to  produce  a  Treatise  on  Chemistry  suflBciently  comprehen- 
■  e  for  those  studying  the  science  as  a  branch  of  general  education,  and  one  which  a  student 
ly  use  with  advantage  in  pursuing  his  chemical  studies  at  one  of  the  colleges  or  medical  schools. 
•  e  special  attention  devoted  to  Metallurgy  and  some  other  branches  of  Applied  Chemistry  renders 
e  work  especially  useful  to  those  who  are  being  educated  for  employment  in  manufacture. 
We  have  in  this  work  a  complete  aud  most  excel 
fiut  text-book  for  the  Uf^e  of  schools,  and  can  heart 
'y  recommend  it  as  Buch. — Boston  Med.  and  Surg 


mm.,  May  28,  1874, 

The  above  is  the  title  of  a  work  which  we  can  most 
V  Miscientiously'recommend  to  students  of  chemistry. 
It  is  as  easy  as  a  work  on  chemisti'y  could  be  made, 
ft  t  the  same  lime  that  it  presents  a  full  account  of  that 

ieace  as  it  now  stands.    We  have  spoken  of  the 

■ik  as  admirably  adapted  to  the  wants  of  students  ; 

::>  quite  as  well  suited  to  the  requirements  of  prac- 


titioners who  wish  to  review  their  chemistry,  orbave 
occasion  to  refresli  their  memories  on  any  point  re- 
lating to  it.  In  a  word,  it  is  a  book  to  be  read  by  all 
who  wish  to  know  what  is  the  chemistry  of  the  pre- 
sent day. — American  Practitioner, Kov.  1873. 

Prof.  Bloxam  possessespre-eminently  Iheinestima- 
ble  gift  of  perspicuity.  It  is  a  pleasure  to  read  bis 
books,  for  he  is  capable  of  making  very  plain  what 
other  authors  frequently  have  left  very  obscure. — 
Va.  Clinical  Record,  Nov.  1S73. 


O 


'LOWES  (FRANK),  D.Sc,  Lovdon. 

Senior  Science-Master  attfie  HighSchool,  Newcastle-Binder  Lyme,  etc. 

AN  ELEMENTARY  TREATISE  ON  PRACTICAL  CHEMISTRY 

AND  QUALITATIVE  INORGANIC  ANALYSIS.  Specially  adapted  for  Use  in  tbe 
Laboratories  of  Schools  and  Colleges  and  by  Beginners.  From  the  Second  and  Revised 
English  Edition,  with  about  fifty  illustrations  on  wood.  In  one  very  handsome  royal 
12mo.  volume  of  372  pages:  cloth,  $2  50.      {Now  Ready.) 


The  methods  are  modern,  and  the  present  approv- 
ed system  of  nomenclature  and  notation  are  used 
exclusively — facts  which  especially  commend  the 
book  to  new  stiidonts  in  qualitative  analysis. —  Chi- 
ca:io  Med.  Journ.  and  Examiner,  Oct.  1S77. 

It  is  short,  concise,  and  eminently  practical.  We 
therefore  heartily  commendit  to  stnden's,  ami  e=pe- 
cially  to  those  who  are  obliged  to  dispense  with  a 
master.  Of  course,  a  teacher  is  in  every  wny  desi- 
rable, but  a  good  degree  of  technicil  nkilland  prac- 
tical knowledge  can  be  attained  with  no  other 
instructor  than  the  very  valuable  handbook  now 
under  consideration. — St.  Louis  Clin.  Record,  Oct. 
1877. 

The  work  is  so  written  and  arranged  that  it  can  be 
comprehended  by  the  student  without  a  teacher,  aud 
the  descriptions  and  directions  for  the  various  work 
are  so  simple,  and  yet  concise,  as  to  be  interesting 


and  intelligible.  The  work  is  unincumbered  with 
theoretical  deductions,  dealing  wholly  with  tbe 
practical  matter,  which  it  is  the  aim  of  this  compre- 
hensive text  book  to  impart.  The  accuracy  of  the 
analytical  methods  are  vouched  fi'r  from  the  fact 
that  they  have  all  been  worked  through  by  the 
author  and  the  members  of  his  class,  from  the 
printed  text.  We  can  heartily  recommend  the  work 
to  the  student  of  chemistry  as  being  a  reliable  and 
comnrehensive  one. — Druggists'  Advertiser,  Oct. 
15,  1S77. 

With  this  manual  before  him  the  advanced  stu- 
dent can  undertake  experiments  without  the  assist- 
ance of  the  professor.  The  aim  of  the  author  has 
been  to  make  it  as  simple  as  possible,  and  for  this 
purpose  he  has  abandoned  many  technical  phrasas, 
and  substituted  therefor  simply  paraphrased  terms. 
—Nashville  Med.  and  Surg.  Journ.,  July,  1877. 


T^EMSENilRA),  M.D.,  Ph.D., 

J.  L  Pf'fessor  of  Cfiemi-ftry  in  tke 


e  ./ohn.t  Hopkins  Unioersity,  Baltimore. 

PRINCIPLES  OP  THEORETICAL  CHI^JMISTRY,  with  special  reference 

to  the  Constitution  of  Chemical  Compounds.     In  one  handsome  royal  12mo.  vol.  of  over 
232  pages:  cloth,  $1  50.      {Just  Issued.) 


For  such  studv,  essential  forexaetness  in  «cieniific 
thought,  I'roi.  Remsen's  book  supplies  viluable  ma- 
terial. Itis  unif  rraly  clearand  logical  Tueauthor 
seldom  overstrnins  a  theory,  and  in  several  cases,  as 
for  instance,  in  his  remirks  on  atomicity  (p.  8t,  et 
se.q.)  point -1  out  diflicitlties  which  are  too  often  over- 
■  looked.  He  has  made  many  things  easy  of  compre- 
P'  hension,  which  are  irenerally  very  difllciilt,  and  al- 
together his  book  will  be  real  treasure  to  earnest 
itudents  —  London  Lanest,  Aug.  1877. 

This  volume  is  devottd  to  the  priui'.iples  upon  which 
the  theoretical  structure  of  modern  chemi'^try  is  based, 
md  as  su'-h  it  is  a  verv  valuable  addition  to  our  litera- 
ture, insomuch  as  it  discusses,  in  a  dear  and  compre- 


Sili    lensive  manner,  the  various  laws  governing  chemical 


combination  and  decomposition,  and  the  various  theo- 
rii'S  whirl)  have  been  advanced  for  explalninir  »n- 
nouuct'd  fai'ts.  In  our  opinior.  the  work  will  prove  to 
be  a  valuable  aid  to  the  chemiciil  student  who  would 
familiarize  himself  with  tlio  theories  of  iliescience  that 
have  led  to  niHny  important  discoveries. — Am.  Journ. 
I'f  r/iarm.,  dune,  1877. 

It  is  an  admirable  presentation  of  the  leading  doc- 
trines of  modern  chemistry.  If  some  subjects  seem 
briefly  treated,  it  is  simpl.v  because  so  little  is  really 
known  about  them,  and  the  author  bus  had  tlie  rare 
good  sense  not  to  lumbi-r  his  pii>;es  with  unprofitable 
speculations  and  mere  "auessesat  tlio  truth." — Boston 
Journ.  of  Chan.,  May,  1877. 


IXrOFfl.ER  AND  FirriG. 

'^   OUTLINES  OF  ORGANIC  CHEMISTRY.     Translatea  with  Ad- 

ditions  from  the  Eighth  German  Edition.     By  Ira.  Remsbn,  M.D.,  Ph.D.,  Professor  of 

Chemii>try  and  Physics  in  Williams  College,  Mass.     In  one  handsome  volume,  royal  12mo. 

of  550  pp.,  cloth,  $3. 

As  the  numerous  editions  of  the  original  attest,  this  work  is  the  leading  te.xt-book  and  standard 

Luthority  throughout  Germany  on  its  important  and  intricate  subject— a  position  won  for  it   by 

he  clearness  and  conciseness  which  are  its  distinguishing  ohnrncteristics.     The  translation  has 

leen  executed  with  the  approbation  of  Profs.  Wiihler  and  Fittig,  and  numerous  additions  and 

Iterations  have  been  introduced,  so  as  to  render  it  in  every  respect  on  a  level  with  the  luost 

dvanced  condition  of  the  science. 


10 


Henry  0.  Lea's  Publications — (Chemistry). 


ATTFIELD  [JOHN),  Ph.D., 

Professor  of  Practical  Chemistry  to  the  Pharmaceutical  Society  of  Great  Britain,  Ac. 

CHEMISTRY,   GENERAL,  MEDICAL,  AND   PHARMACEUTICAL  ; 

including  the  Chemistry  of  the  U.  S.  Pharmacopoeia.     A  Manual  of  the  General  Principles 
of  the  Science,  and  their  Application  to  Medicine  and  Pharmacy.      Seventh  American  edi- 
tion, reviset  from  the  Si.xth  English  edition  by  the  author.     In  one  handsome  royal  12mo. 
volume  of  66S  pages,  with  87  illustrations:  cloth,  $2  75  ;   leather,  $3  25       (J//st  Issued.)  . 
This  work  has  received  a  very  careful  revision  at  the  hnnds  of  the  author,  result  in  gin  a  conside- 
rable increase  in  size,  together  with  the  addition  of  a  handsome  series  of  illustrations      Notwith- 
standing these  improvements,  the  price  has  been  maintained  at  the  former  very  moderate  rate. 


It  is  a  valuable  work  for  the  busy  practitioner,  ex- 
cludiug  as  it  does  everythiiif;  that  would  be  of  ia'e- 
rest  ouly  to  the  scientific  chemist,  and  having  acom- 
jirehensive  index  wliicli  renders  after  consultation 
easy.  That  portion  devoted  to  urinalysis  and  prac- 
tical toxicology,  and  the  tests  for  im  purities  in  medi- 
cinal prep.irAtions,  is  especially  valual)le  to  the 
prac'ising  physician.  For  the  student  it  is  desirable, 
lor  the  reason  that  it  is  so  arranged  that  he  may, 
without  an  instnic'or,  study  the  science  experiment- 
ally.— Am.  I'ractitiouer,  March,  1S77. 

After  liavin-r  used  it  as  a  text-book  in  the  laboratory 
of  the  Philadelphia  College  of  Pharmacy  durinj;  the  last 
five  years,  we  can  speak  from  our  own  experience,  and 
testify  to  its  intrinsic  value  in  tbe  instruction  of  the 
student.  The  more  we  have  used  it,  the  more  we  were 
pleased  with  it,  and  on  tbeappearanceof  a  new.revised. 
and  enlarged  edition,  we  take  occasion  to  again  cordi- 
ally recommend  it,  belioTing  that  for  the  practical  in- 
struction of  pliarmnceutical  students  in  chemistry  it 
hn-!  no  superjnr  in  the  English  language. — Am.  Journ. 
of  Pliarm..  Nov.  1876. 

The  book,  by  a  well  arranged  system,  introduces  the 
student  into  the  Science  of  Chemistry,  giving  him  at 
each  >tep  sufficient  information  to  enable  him  to  per- 
form experiments  witli  his  own  hands;  theexperiments 
are  partly  of  synthetical  and  partly  of  analytical  inte- 
rest: iu  this  way  the  editor  succeeds  aiimirably  in 
avoiding  a  dry  monotonous  enumeration  of  facts.    The 


rariety  which  he  gives  is  certainly  well  calculated  to 
prevent  the  reader  from  petting  tired.  This  variety. 
iKwever.  is  not  such  as  to  bewilder  the  mind,  nor  are 
the  experiments  described  calculated  only  to  serve  ns  a 
pleasant  pastime.  The  student  who  reads  tbe  book  mid 
executes  the  experiments  mentioned,  cannot  help  but 
fe-1  deeply  interested  in  the  subject,  and  indeed,  will, 
going  through  the  practical  work,  finti  it  a  very  agrce- 
:ible  recreation. — Cincinnati  Clinic.  I  let  28.  1K76. 

It  brings  up  our  knowledge  of  the  subject  to  the  pre- 
sent date,  and  has  been  enriched  with  numerous  wood 
engravings  illustrative  of  apparatus  and  modes  of  work. 
I'he  arranirement  of  the  work  is  admirnblcaud  to  each 
element  its  more  important  compounds  used  in  medi- 
eineor  pharmacy  are  given,  together  wit.b  both  syntheti- 
cal fend  analyli(!al  reactions.  The  systematic!  analysis 
of  compounds,  substances  or  tluids  is  also  treated  of, 
and  copious  tables  are  given  showing  the  modes  of  sy.s- 
tematically  separating  the  different  elements  from  one 
another. — Canada  Med.  and  Surg  Journ  ,  Nov.  187G. 

As  a  compact  manual  of  the  general  principles  of  the 
science  and  their  applications  in  medicine  and  phar- 
macy it  has  no  rival,  and  the  frequent  and  thorough 
revision  it  receives  keeps  it  iuall  re«pects  up  with  the 
times  The  American  edition,  whii'h  covers  the  United 
States  Pharmacopoeia,  is  prepared  under  the  author's 
supervision — Button  Journal  of  Che  mi  shy.  Nov.  1^70. 

Admirably  a  la'ited  to  the  use  of  medical  .students.— 
Atlanta  Med.  Journ.,  Oct.  1876. 


POWNES  {GEORGE),  Ph.D. 

A  MANUAL  OF  ELEMENTARY  CHEMISTRY ;  Theoretical  and 

Practical.     Pievised  and  corrected  by  Hf.nry  Watt.s,  B.A.,  F  R.S.,  author  of  'A  Diction- 
ary of  Chemistry,"  etc.     With  a  colored  plate,  and  one  hundred  and  seventy-seven  illus- 
trations.    A  new  American,  from   thi  twelfth  and  enlarged  London  edition.     Edited  by 
Robert  Bridge.s,    M.D.        In   one   large   royal    12mo.   volume,   of  over   1000    pages; 
cloth,  $2  75  ;  leather,  $3  25.     (Now  Ready.) 
Two  careful  revisions  by   Mr.  Wntts,  since  the  appear.ance  of  the  last  American  edition  of 
"  Fownes,"  have  so  enlarged  the  work  that  in  England  it  has  been  divided  into  two  volumes.     In 
reprinting  it,  by  the  use  of  a  sina'l  and  e.xceedingly  clear  type,  cast  for  the  purpose,  it  has  been 
found  possible  to  comprise  the  whole,  without  omission,  in  one  volume,  not  unhandy  for  study  and 
reference.    The  enlargement  of  the  work  has  induced  the  American  Editor  to  confine  his  additions 
to  the  narrowest  compass,  and  he  has  accordingly  inserted  only  such  discoveries  us  have  been  an- 
nounced since  the  very  recent  nppearanee  of  the  work  in  England,  and  has  addec"  the  standards 
in  popular  use  to  the  Decimal  and  Centigrade  systems  employed  in  the  original. 

Among  the  additions  to  this  edition  will  be  found  a  very  handsome  colored  plate,  representing 
a  number  of  spectra  in  the  spectroscope.  Every  care  has  been  taken  in  the  typographical  execu- 
tion to  render  the  volume  worthy  in  every  respect  of  its  high  reputation  and  e.xtended  use,  and 
though  it  has  been  enlarged  by  more  than  one  hundred  and  fifty  pages,  its  very  moderate  price 
will  still  maintain  it  as  one  of  the  cheapest  volumes  accessible  to  the  chemical  student. 


T>OWMAN  [JOHN  E.) ,  M.  D. 

PRACTICAL  HANDBOOK  OF  MEDICAL  CHEMISTRY.    Edited  i 

by  C.  L.  Bloxam,  Professor  of  Practical  Chemistry  in  King's  College,  London.      Si.xth  | 
American,  from  the  fourth  and  revised  English  Edition.     In  one  neat  volume,  royal  12mo., 
pp.  351,  with  numerous  illustrations:  cloth,  S2  25. 
pr  THP,  SAME  AUTHOR.    (Lately  Issued.)       

INTRODUCTION   TO   PRACTICAL  CHEMISTRY,  INCLUDINQt 

ANALYSIS.     Sixth  American,  from  the'sixth  and  revised  London  edition.    With  numer 
ous  illustrations.     In  one  neat  vol.,  royal  12mo.,  cloth,  $2  25. 


KNAPP'S  TECHNOLOGY  ;  or  Chemistry  Applied  to 
the  Arts,  and  to  Manufactures.  With  American 
additions  by  Prof.  AVai.ter  R.  Johnson.     In  two 


very  handsome  octavo  volumes,  with   .000  wooi 
engravings,  cloth,  $6  00. 


;l  1 


HsNRY  C.  Lea's  Publications — (Chemistry). 


11 


T>LOXAM  [C.  L.), 

-*-'  Profennor  of  ChemUtry  in  King'' s  College,  London. 

CHEMISTRY,  INORGANIC  AND  ORGANIC.     From  the  Seoonrl  Lon- 

don  Edition.  In  one  very  handsome  octavo  volume,  of  700  pages,  with  about  300  illustra- 
tions. Cloth,  $4  00;  leather,  $5  00.  {Just  Issued.) 
^  It  has  been  the  author's  endeavor  to  produce  a  Treatise  on  Chemistry  sufBciently  comprehen- 
aive  for  those  studying  the  science  as  a  branch  of  general  education,  and  one  which  a  student 
may  use  with  advantage  in  pursuing  his  chemical  studies  atone  of  the  colleges  or  medical  schools. 
The  special  attention  devoted  to  Metallurgy  and  some  other  branches  of  Applied  Chemistry  renders 
the  work  especially  useful  to  those  who  are  being  educated  for  employment  in  manufacture. 

We  have  in  this  work  a  complete  and  most  excel- 
lent text-book  for  the  UPS  of  schools,  and  can  heiirt- 
ily  recommend  it  as  fuch. — Boston  Med.  and  Surg. 
Journ.,  May  28,  1874. 


The  aboveis  the  title  of  a  work  which  we  can  most 
conscientiously  recommend  to  students  of  chemistry. 
It  is  as  easy  as  a  work  on  chemistry  could  be  made, 
at  the  same  time  thatit  presents  a  full  account  of  that 
science  as  it  now  stands.  We  have  spoken  of  the 
work  as  admirably  adapted  to  the  wants  of  students  ; 
It  is  quite  as  well  suited  to  the  requirements  of  prac- 


titioners who  wish  to  re  view  their  chemistry,  or  have 
occasion  to  refresh  their  memories  on  any  point  re- 
lating to  it.  In  a  word,  it  is  a  book  to  b(>  read  by  all 
who  wish  to  know  what  is  the  chemistry  of  the  pre- 
■sent  day. — American  Practitioner ,'^ox .  1873. 

Prof.  Bloxam  possessespre-eminently  the  inestima- 
ble gift  of  perspicuity.  It  is  a  pleasure  to  read  his 
books,  for  he  is  capable  of  making  very  plain  what 
other  authors  frequently  have  left  very  obscure. — 
Va.  Clinical  Record,  Nov.  1873. 


pLOWES  (FRANK),  D.Sc,  Lovdon. 

'-'  Senior  Science-Master  at  the  High  School,  Newcastle-under  Lyme,  etc. 

AN  ELEMENTARY  TREATISE  ON  PRACTIC  A  L  CHEMISTRY 

AND    QUALITATIVE  INORGANIC   ANALYSIS.     Specially  adapted  for  Use  in  the 
Laboratories   of  Schools  and  Colleges  and  by  Beginners.     From  the  Second  and  Revised 
English  Edition,  with  about  fifty  illustrations  on  wood.      In  one  very  handsome  royal 
12mo.  volume  of  372  pages:  cloth,  $2  50.      {Nou>  Ready.) 
The  methods  are  modern,  and  the  present  approv- 
ed   system  of  nomenclature  and   notation  are  used 
exclusively — facts  which   especially  commend  the 
book  to  new  stndnnts  in  qualitative  analysis.— CAi- 
car/o  3fed.  Journ.  and  Examiner,  Oct.  1877. 

It  is  short,  concise,  and  eminently  practical.  We 
therefore  heartily  commend  it  to  stnden's,  and  e--pe- 
cially  to  tho>e  who  are  obliged  to  dispense  with  a 
master.  Of  course,  a  teacher  is  in  every  way  desi- 
rable, but  a  good  degree  of  technictl  s-liilland  prac- 
tical knowledge  can  be  attained  with  no  other 
instructor  than  the  very  valuable  handbook  now 
under  consideration. — St.  Louis  Clin.  Record,  Oct. 
1877. 

The  work  is  so  written  and  arranged  that  it  can  be 
omprehended  by  tlie  student  without  a  teacher,  and 
the  description-;  and  directions  for  the  various  work 
re  so  simple,  and  yet  concise,  as  to  be  interesting 


R 


and  intelligible.  The  work  is  unincumbered  with 
theoretical  deductions,  dealing  whidly  with  the 
practical  matter,  which  it  is  the  aim  of  this  compre- 
hensive text  book  to  impart.  The  accuracy  of  the 
analytical  methods  are  vouched  for  from  the  fact 
that  they  have  all  been  worked  through  by  the 
author  and  the  members  of  his  class,  from  the 
printed  text.  VVe  can  heartily  recommend  the  work 
to  the  student  of  chemistry  as  being  a  reliable  and 
comprehensive  one. — Druggiats'  Advertiser,  Oct. 
15,  1877. 

With  this  manual  before  him  the  advanced  stu- 
dent can  undertake  experiments  without  the  assist- 
ance of  the  professor.  The  aim  of  the  author  has 
been  to  make  it  as  simple  as  possible,  and  for  this 
purpose  he  has  abandoned  many  technical  phrases, 
and  substituted  therefor  simply  paraplirase.l  terms. 
— Na.shviile  Med.  and  Surg.  Journ.,  July,  1877. 


EMSEiViIRA),  M.D.,  Ph.D., 

Pr'ifc.K.tor  of  ChemiHry  in  the  Johnu  Hopkina  Uuioer.sity,  Bnltimnre. 

PRINCIPLES  OF  THEORETICAL  CH!<:MISTRY,  with  special  reference 

to  the  Constitution  of  Chemical  Compounds.     In  one  handsome  royal  12mo.  vol.  of  over 
232  pages:  cloth,  $1  50.     (Just  Issued.) 


For  such  studv,  essential  forexactness  in  scientific 
bought.  Pi'o!.  Remsen's  book  supplies  valuable  ina- 
erial.  It  is  uuif  rmly  clearand  logical  Ttieauthor 
eldom  overstmins  a  theory,  and  in  several  casps,  as 

r  instance,  in  his  remirks  on  atomicity  (p  81,  et 
sq.)  point-!  out  difficultieswhichare  too  ofien  over- 
Joked.  He  has  made  many  things  easy  of  compre- 
ension,  wbirh  are  ijenerally  very  diflicult,  and  al- 

'gether  his  book  will  be  real  treasure  to  earnest 
;udent8  -  London  Lanest,  Aug.  1877. 

This  volume  i')  devoted  to  the  principles  upon  which 
ic  theoretical  structure  of  modern  chemi-^try  is  l):ise<l, 
id  a?  su'-h  it  is  a  very  valuable  addition  to  our  litera- 

re.  in.^oniuch  as  it  discus.ses,  in  a  clear  and  compre- 
^nsive  manner,  the  various  laws  governing  chemical 


combination  and  decomposition,  and  the  varioustheo- 
rii'S  whi-h  have  been  advanced  for  explaining  an- 
nounced facts.  In  ouropinior.  the  work  will  prove  to 
be  a  valuable  a'd  to  thecliemicni  stuilent  who  would 
familiarize  himself  with  the  Iheoriesofihe  science  that 
have  led  to  iniiny  important  discoveries. — Am.  Journ. 
if  I'harm.,  .)uno,  1877. 

It  is  an  admirable  presentation  of  the  lending  doc- 
trines of  modern  chemistry  If  some  subJLM-ts  seem 
briefly  treated,  it  is  simply  becnnse  so  liltli-  i-^  rinlly 
known  about  them,  and  the  author  has  had  iho  raro 
good  sense  not  to  lumhiT  his  pages  with  iuiprofit«bl(< 
speculations  and  mere  "  guesses  at  tho  truth  " — Jiviton 
Journ.  of  Olicm.,  May,  1877. 


UrOHLER  AND  FIT  TIG. 

^^  OUTLINES  OF  ORGANIC  CHEMISTRY.  Tianslate.l  with  Ad- 
ditions from  the  Eighth  German  Edition.  By  Ira  Remskn,  M.D.,  Ph.D.,  Professor  of 
Chemi.stry  and  Physics  in  Williams  College,  Mass.  In  one  handsome  volume,  royal  12mo. 
of  550  pp.,  cloth.  $3. 

As  the  numerous  editions  of  the  original  attest,  this  work  is  the  leading  text-hook  and  standard 

ithority  throughout  Germany  on  its  important  and  intricate  subject— a  position  won  for  it   by 

I e  clearness  and  conciseness  which  are  its  distinguishing  chnrncteristics.  The  trnn.sjation  haa 
ien  executed  with  the  approbation  of  Profs.  Wiihler  and  Fittip,  and  numerous  additions  nnd 
ierations  have  been  introduced,  so  as  to  render  it  in  every  respect  on  a  level  with  the  most 


12        Henry  C  Lea's  Fublic axioms — {Mat.  Med.  and  Therapeutics). 


JDARRISH  {EDWARD), 

Late  Professor  of  Materia  Mediea  in  the  Philadelphia.  College  of  Pharmacy. 

A  TREATISE  ON   PHARMACY.     Designed  as  a  Text-Book  for  the 

Student,  and  as  a  Guide  for  the  Physician  and  Pharmaceutist.     With  many  Formulae  and 
Prescriptions.     Fourth  Edition,  thoroughly  revised,  by  Thomas  S.  Wiegand.     In  one 
h:indsome  octavo  volume  of  977  page^;,  with  280  illustrations ;  cloth,  $6  60;  leather,  $6  50. 
(Lately  Issued  ) 
The  delay  in  the  appearance  of  the  new  U.  S.  Pharmacopoeia,  and  the  sadden  death  of  the  au- 
thor, have  po.«tponed  the  preparation  ofthis  new  edition  beyond  the  period  expected.     Thenotes 
and  meinoriinda  left  by  Mr.  Parrish  have  been  placed  in  the  hands  of  the  editor,  Mr.  Wiegund, 
who  has  labored  assiduously  to  embody  in  the  work  all  the  improvements  of  pharmaceutical  sci- 
ence which  have  been  introduced  during    he  Inst  ten  years.     It  is  therefore  hoped  that  the  new 
edition  will  fully  maintain  the  reputation  which  the  volume  has  heretofore  enjoyed  as  a  standard 
text-book  and  work  of  reference  for  all  engaged  in  the  preparation  and  dispensing  of  medicines. 
01   Dr    Parrish's  great  work  on  vh"iniacy  it  only  :  an  honored  place  on  our  own  book^hfilvfes. — Dublin 
remwins  to  be  .•«aid  thai  the  editor  has  accoroplished  ;  Me4  Prenn  and  Circular,  Aug.  12,  1S74. 
hi-  work  so  well  as  to  maintain,  in  this  fourth  edi-  -      vTe  expres.sed  onr  opinion  of  a  former  edition  in 
tion,  I  he  high  standard  of  excellence  which  it  bad     tgrms  of  unqualified  praise,  aud  we  are  in  no  mood 
aitaiuediu  previous  editions,  under  the  editorship  of    to  detract  from  that  opiuion  in  rfference  to  the  pre- 
it- accinplislied  anthor      This  has  not  been  accom      sent  edition,  the  preparation  of  which  has  fallen  into 
pli-lied  without  much  labor,  and  many  additions  and     competent  hands.  It  is  a  book  with  which  no  pharma- 
improv-iireuts,iuvolvingthaDgesiuthearrangPB;ent    ^j^,  ^^n  dispense,  and  from  which  no  phy.sician  can 
of     hp  several  parts  of  the  work,  aud  the  addition  of    f^jj  (^  derive  much  iuforraarion  of  value  to  him  in 
much  new  matier.     With  the  modifications  thus  et-    practice.— P«ci^c  Med.  and  Surg.  Jonrn.,  June,  '74. 
fecied  it  constitutes, as  uow  presented,  a  compendium 

of  tlie  fcieuce  and  art  indi-pensable  to  the  phariua- 1  With  the«e  few  remarks  we  heartily  commend  the 
cist,  and  ol  the  utmost  value  to  every  practiiioner  .  work,  and  have  no  doubt  that  it  will  luaiotain  its 
of  lii.dicine  desirous  of  familiarizing"  himself  with  old  reputation  as  a  textbook  for  the  student, and  a 
the  phaiinaceutical  preparation  of  the  articles  which  work  of  reference  for  the  more  experienced  physi- 
he  pre-cribesforhispatient»  — C/*ic<jyo  Jfed.J^owrn.,  cian  and  pharmacist .—  C/ucairo  Med.  Examiner, 
July   1S74.  I  Juoel.'i,  1S74. 

The  work  is  eminently  pra  tical,  and  has  the  rare  !  Perhaps  one,  if  not  the  most  important  book  npoa 
merit  olbeiug  readable  Hud  interesting,  while  it  pre- '  pharmacy  which  has  appeared  iu  the  English  Ian- 
serves  astric  ly  scieuiiliccliaracter  Thewholework  gUKge  has  emanated  from  the  transatlantic  press., 
retlects  the  greatest  credii  on  author,  editor,  and  pub-  "  Parrishs  Pliarmacy'  is  a  well-known  work  on  thil 
lishpr  It  wil Icouveysoirip idea  ofr he  liberality  which  side  of  the  water,  aud  the  fact  shows  us  that  a  really 
has  lippu  bestowed  upi-n  its  production  when  we  men-  useful  work  never  becomes  merely  local  in  its  fame. 
tion  that  there  are  no  less  than  2S(i  carefully  executed  Thanks  to  the  judicious  editing  of  Mr.  Wiegand,  th« 
illustrations.  In  conclusion,  wp  beanily  recommend  posthumous  edition  of  "Parrish"  has  been  saved  t» 
the  Work  not  only  to  pharmaiists.  but  also  to  the  ;  the  public  with  all  the  mature  experience  of  its  an- 
muUitude  of  medical  practiiiouers  who  are  obliged  thor,  ano  perhaps  none  the  worse  for  a  dash  of  new 
to  compound  their  own  medicines.     It  will  ever  hold  [  blood.— iowd.  Pharvi.  Journal,  Oct.  17,  1874. 


OTILLE  {ALFRED),  M.D., 

O  Professor  of  Theory  and  Practice  of  Medicine  in  the  University  of  Penna. 

THERAPEUTICS  AND  MATERIA  MEDICA;  a  Systematic  Treatise 

on  the  Action  and  Uses  of  Medicinal  Agents,  including  their  Description  and  History. 
Fourth  edition,  revised  and  enlarged.    In  twolarge  and  handsome  8vo.  vols,  of  about  2000  t 
pnges.      Cloth,  $10;   leather,  $12.      {Late/y  Issued.) 
The  care  bestowed   by  the  author  on  the  revision  of  this  edition  has  kept  the  work  out  of  the 
market  for  nearly  two  years,  and  has  increased  its  size  about  two  hundred  and  fifty  pages.    Not 
withi^tanding  this  enlargement,  the  price  has  been  kept  at  the  former  very  moderate  rate. 

It  is   unnecessary  to  do   much   more   than   to  an-    of  thp  pre-ent  edition,  a  whole  cyclopsedia  of  thera- 
Bounce  the  appearance  of  the  fourth  edition  of  this    peutics. — Chicigo  MtdicalJourHtil,Vv\>.  Milo. 
well  known  and   exc'llemwork— Sri^.  and   For.         The  magnificent  work  of  Professor  Stille  is  knowgSi 
Med.-Chir.  Heview, Oct  lb75.  !  wherever  the  English  language  is  read,  and  the  art.'i 

For  all  who  desire  a  complete  work  on  therapeutics  '  of  medicine  cultivated  ;  known  so  well  that  no  enco- 
and  materia  mediea  for  reference,  iu  cases  involving  miuin  of  ours  could  brighten  its  fame,  and  no  unfa- 
medico-legal  questions,  as  well  as  for  information  vorable  criticism  could  tarnish  its  reputation. — Phil' 
coucerniug  reinedial  agents,  Or.  Still6"8is  "par  t.x-  |  aJelphia  Med    Times,  Dec.  12.  IS74 

■   -    •  "■  •  The  rapid  exhaustion  of  three  editions  aud  tlie  nni- 

versal  favor  with  which  the  work  has  been  received 


ce'i^HCi' the  work      The  work  being  oui  of  print,  by 

the  exhaustion  of  former  editions  the  author  has  laid ...      . 

the    profession    under  renewed    obligations,  by  the    by  the  medical  profession,  are  sutficieut  proof  of  its 


careful  revision,  important  additions,  and  timely  re- 
issuing a  work  not  exactly  supplemented  by  any 
othfr  in  the  English  language,  if  in  any  language 


excellence  as  a  repertory  of  practical  and  useful  in- 
formation for  the  physician.  The  edi;ii>n  before  us 
fully  sustains  this  verdict,  as  the  work  lias  bepn  care- 


The  mechanical  execution  handsomely  sustains  the  fully  revised  and  in  some  portions  rewritten,  bring' 
well-known  skill  and  good  taste  of  ihe  publisher. —  j^g  jt  np  to  the  present  time  by  the  admission  of 
St.  Louis  Med.  and  Siiro  Jonrnol,  Dec   1874.  i  chloral  and  cmtou  chloral,  nitrite  of  iimyl,  bichlo- 

The  prominent  feature  of  Dr.  Still6  s  great  work  ride  of  methylene,  methylic  ether,  lithium  com- 
is  sound  good  sense.  It  is  le.rned.  but  it*  learning  pounds,  gelspminum,  and  other  remedies.— -4»». 
is  of  inferior  value  compared  wiih  the  discrimiuating  j  Journ   of  Pharmacy,  Feb.  1S7.J. 

judgment  which  is  shown  by  its  author  inthedis-  -we  can  hardly  admit  that  it  has  a  rival  in  the 
cussion  of  his  subjects,  aud  which  renders  it  a  trust-  ,  maUitade  of  its  citations  and  the  fulness  of  its  re- 
worthy  guide  in  the  siok-room.— .ilrn.  Practitioner,  search  into  clinical  histories,  and  we  must  assign  it 
Jan.  lS7.i.  |  a  place  in  the  physician's  library;  not.  indeed,  as 

From  the  publication  of  the  first  edition  "Still^'s  fully  lopresenting  the  present  siatp  of  knowledge  in 
Therapeutics"  has  been  one  of  the  classics;  its  ab-  i  pharmacodynamics,  but  as  by  far  the  most  complete 
sence  from  our  libraries  w.iuld  create  a  vacuum  \  treatise  upon  the  clinical  and  practical  side  ol  the 
which  conld  be  filled  by  no  other  work  in  the  Ian-  question.— Bo«to»  Mtd.  and.  Surg.  J'nirnal,  Nov.  5, 
gaage,andits  presence  supplies,  in  the  two  volumes    1S74. 


Henry  C.  Lea's  Publications— (ITai!.  Med.and  Therapeutics).       13 


iJTILLE  {ALFRED),  M.  /),  LL.D.,  and    IfAlSCH  [JOHN  M.).  Ph.D.. 

P'^2^  l^fTli-yry  and  Practice,  of  Clinical  lf±        Prof.  „f  Mat.  MeA.  and  Bot   in  Philn. 

Med.  xn  Uw  v.  of  Pa.  Coll.  Phnrmnc.,,.  S-.cy.  to  the  American 

r^.^,^   ,, P/tarmnc-nticfil  Ann'icintion. 

THE  N/ITIONAL  DISPENSATORY:  Embracing  the  Chemistry.  Botany, 

Materia  Mediea,    Pharmacy,    Pharmacodynamics,  and  Thenipetities  of  the  Pharmaco- 
poeias of  the  United  Stiites  and  Great  Britain.     For  the  Use  of  Physicians  and  Pharma- 
ceutists.    In  one  hanisome  octavo  volume,  with  numerous  illustrations.     {In  Preas.) 
The  w:int  has  long  been  felt  and  e.'cpres.'sed  of  a  work  which,  within  a  mod»rnte  compass, 
should  gi^e  to  the  phvsieian  and  pharmaceutist  an  authoritative  exposition  of  the  Pharmneo- 
nneias  from  the  existing  standpoint  of  medicil  and  pharm  iceutical  .science.     For  s^vernl  years 
he  iiuthors  have  been  earnestly  engaged  in  the  preparation  of  the  present  volume,  with  the 
hope  of  satisfying  this  w:int,  and  their  labors  are  now  suflbiently  advanced  to  enable  the  pub- 
iisher  to  promise  its  appearance  during  the  coming  season      Their  distinguished  reputation  in 
their  respective  departments  is  a  guarantee  that  the  worlc  will  fulfil  all  reasonable  e.xpectiition  as 
A  guide  in  the  selection,  compounding,  dispensing,  and  medicinal  use.s  of  drugs,  complete  in  all 
respects,  while  convenient  in  size,  and  carefully  divested  of  all  unnecessary  and  obsolete  niatter. 

TffARQUHARSON  [ROBERT),  M.D., 

-*•  LeHnrer  on  Materia  Wedica  nt  St.  Mary^fi  HosjAtal  Mf.dical  Srhnnl. 

A  CxUIDE  TO  THERAPEUTICS.     Edited,  with  Additions,  embracing 

the  U.  S.  Pharraacopojia.  By  Frank  Woodbury-,  M.D.  In  one  neat  volume,  rojal 
12tno.  volume  of  over  400  pages:  cloth,  $2.      (Novj  Ready.) 

The  object  of  the  author  has  been  to  present  in  a  compact  and  compendious  form  the  the- 
rapeutics of  the  Materia  Medica,  unincumbered  by  botanical  and  pharmaceutical  details.  The 
volume  is  thus  emphatically  a  work  for  the  medical  student,  to  aid  in  hi?  acquiring  a  clear  and 
connected  view  of  the  subjtct  in  its  most  modern  aspects;  and  for  the  busy  practitioner  who 
may  wish  to  refresh  his  memorv.  Under  each  article,  in  parallel  columns,  are  given  its  phy- 
siological and  therapeutical  actions,  thus  enabling  the  rearler  to  take  in  at  a  glance  the  essential 
facts  with  respect  to  each  remedy,  and  numerous  formuIjB  are  given  as  examples  of  their  prac- 
tical use.  Considerable  additions  have  been  introduced  by  Dr.  Woodbury,  who  has  made 
numerous  changes  to  adapt  the  work  to  the  wants  of  the  American  student,  introducing  all  the 
preparations  of  the  U.  S.  Pharmacopoeia,  and  many  of  the  newer  remedies. 

This  little  voluuie  is  an  earnest  etTDrt  to  advance  1  manner,  tbat  it  deserves  cnreful  stiuiy  by  every  stu- 
the  iufeieslK  of  iotelligent  iherapeutics.  In  a  mode-  i  dent  and  voung  practitiouer. —  Cincii-nati  Clinic 
-        -    '     ■    ■         - '     ■     -  •  Jan.  12,  187S. 

Many  persons  who  learned  therftpeulirs  before 
the  physiological  action  of  remedies  was  taiiijht  t" 
students  find  it  difficult  to  discover  the  bearing  of 
pliysi<iloeical  action  oo  liierapeutic  einployinent 
from  ordinary  textbooks.  Dr.  Kaniuharson  ha's  most 
iugeuiously  'ihown  it  by  printing  Die  two  in  parallel 
columns  and  corresponding  paiairraphx,  to  tbat,  by 
miming  the  eye  down  the  left-hand  side  of  a  pn  j;e  we 
get  the  pliysioIogiOHl  actions  of  a  drug,  and  on  the 
riglit-band  the  tlierapeutical  uses,  wlijle,  by  running 
it  straight  across  the  page,  we  at  once  perceive  the 
relations  of  the  one  to  the  other.  On  this  account,  the 
work  is  likely  to  be  useful,  not  only  to  students  pre- 
paring for  their  examinations,  bnt  to  those  nu'dical 
men,  also,  who  are  well  acquainted  with  larger 
books  on  the  same  subject,  but  experience  the  dilH- 


rate  compass  we  find  he  established  facts  concerning 
the  physuil<igical  and  therapeutical  actions  of  reme- 
dies. Tlie  corre^pondina;efi■ects  of  different  remedies 
in  health  and  disease  are  presented  in  parallel  col- 
umns. This  arraogement  impre^sps  us  very  favor- 
ably, as  both  convenient  and  c-ilculated  to  stamp 
the  facts  ution  the  memory.  We  d  )  not  know  of  an 
equal  number  of  pages  in  one  work  that  con  ains  for 
the  needs  of  the  student  anything  near  as  valuable 
an  account  of  these  substinces  We  can  cordially 
commend  this  work  to  themedical  stndfnt  a.'  the  best 
introduction  to  th«  study  of  larger  and  more  elabo- 
rated treati^es  — Detroit  Lancet,  Jan    IS7S. 

An  excellent  feature  of  r>r  Farquharson's  Guide, 
and  one  which  will  commend  it  to  all  earnest  stu- 
dents, is  the  arraugemeat,  in  tabular  form,  of  the  va- 
rious officinal  preparations  and   their  dose,  so  that 

they  may  be  readily  committed  to  memory  This  ,  culty,  already  mentioned,  of  seeing  the  relations 
handbook  is  so  well  arranged,  and  presents  the  well  ,  between  the  a'-tions  and  use  of  remedies.  —  The 
established  facts  of  therapeutics  in  so  impressive  i  [  London  Practitioner,  January,  1978. 


QRIFFITH  [ROBERT  E.),  M.D. 

A  UNIVERSAL  FORMULARY,  Containing  the  Methods  of  Prepar- 

ing  and  Administering  Officinal  and  other  Medicines.    The  whole  adapted  to  Physicinr  s  and 
Pharmaceutists.     Third  edition,  thoroughly  revised,  with  numerou.s  additions,  1)3  Joii.n  M. 
Maisch,  Professorof  Materia  Medica  in  the  Philadelphia  College  of  Pharmacy.   In  one  largo 
and  handsome  octavo  volume  of  aboutSOOpp.,  cl.,  $4  50  .leather,  $5  50.    (Lately  f.isiied.) 
As    a  comparative  view  of  the  United  States,  the    British,  the  (ieriuan,  and    the    French 
Pharmacopoeias,  together  with  an  immense  amount  of  unofficinal  formulas,  it  afTonl.s  to  the  prac- 
titioner and  pharmaceutist  an  aid  in  their  daily  avocations  not  to  be  found  elsewhere,  while  three 
indexes,  one  of  "Diseases  and  their  Remedies,"  one  of  Pharmaceutical  Names,  and  a  lieneral 
Index,  afford  an  easy  key  to  the  alphabetical  arrangement  adopted  in  the  text. 

To  the  druggist  a  good  formulary  is  simp'y  indis- 
pensable, and  perhaps  no  formulary  has  been  ririre 
.extensively  used  than  the  well-kuowu  work  before 
us.  Many  physicians  have  to  officiate,  also,  as  drug- 
gists. This  is  true  especially  of  the  country  physi- 
cian, and  a  work  which  shall  teaoh  hiiu  the  means 
by  which  to  administer  or  combioe  his  remedies  in 
the  most  efficacious  and  pleasant  manner,  will  .il- 
ways  hold  its  place  upon  his  shelf  .<  formulary  of 
this  kind  is  of  benefit  also  to  the  city  physician  in 
largest  practice.— Ci»einnati  Olinic,  Feb.  21,  1374. 


A  mor«  complete  formulary  than  it  Is  in  its  pres- 
ent form  the  pharmacist  or  pliysidHn  could  hardly 
desire  To  the  llr.^t  some  surh  work  is  iMlli>^^en^a- 
ble,  and  it  is  hardly  less  es-^ential  to  the  practitioner 
who  compounds  his  own  m'-dirliiet.  Much  of  what 
is  contained  in  the  introduction  ought  to  be  com- 
mitted to  memory  by  Bvery  student  of  meilicine. 
As  a  help  to  pliy>irianM  It  will  bi-  found  invaluable, 
and  doubtless  will  make  its  way  into  libraries  not 
already  supplied  with  a  standar.l  work  of  the  kind  . 
—  T/ie  Ammrican  Practitioner,  Louisville,  July,  '74. 


14 


Henry  C.  Lea's  Publications — {Pathology^  &c.). 


AND 


rjORNIL  (F.), 

Prof,  in  the  Faculty  of  Me.d  ,  Paris. 


J^ANVIER  (L.), 

Prof,  in  the  College  of  France. 

MANUAL  OF    PATHOLOGICAL    HISTOLOGY.     Translated,  with 

Notes  and  Additions,  by  E.  0.  Shakespeahe,  M.D.,  Pathologist  and  Ophthalmic  Surgeon 
to  Pbilada.  Hospital,  Lecturer  on  Refrpction  and  Operative  Ophthalmic   Surgery  in  Univ. 
of  Penna.     In   one  very  handsome  octavo  volume  of  about  600  pages,  with  over  300  illus- 
trations      (Prepannff.) 
So  much  has  been  done  of  late  years  in  the  elucidation   of  pathology  by  means  of  the  micro- 
scope, and  this  subject  now  occupies  so  prominent  a  position  as  one  of  the  most  important  branches 
of  medical  science,  that  the  American  profession  cannot  fail  to  welcome  a  translation  of  the  pre- 
sent work,  which,  through  its  own   merits  and  through  the  well-known  reputation   of  its  distin- 
guished authors,  is  regarded  in  Europe  as  the  standard  text-book  and  work   of  reference  in  its 
department      Such  investigations  and  discoveries  as  have  been  made  since  its  appearance  will  be 
introduced  by  the  translator,  and  the  work  is  eonfiderliy  expected  to  assume  in  this  country  the 
same  position  which  has  been  so  universally  accorded  to  it  abroad. 

L^EN  WICK  ( SA  M  UEL),  M.  D . , 

-'-  Assistant  Physician  to  the  London  Hospital. 

THE  STUDENT'S  GUIDE  TO  MEDICAL  DIAGNOSIS.     From  the 

Third  Revised  and  Enlarged  English  Editior.  With  eighty-four  illustrations  on  wood. 
In  one  very  handsome  volume,  royal  ]2mo.,  cloth,  $2  26.  (Just  Issued.) 
Of  the  m«ny  guidp-l)ooks  ou  niedica.1  diiiguo.-is, 
claimed  to  be  written  for  tlip  special  insfiicilun  of 
etudenis,  thi>  is  the  best.  Theaulhor  is  evidently  a 
well  read  and  nccompli'^bed  physician. and  be  knows 
how  to  teach  practical  medicine.  The  charm  of  sim- 
pliciiy  is  not  the  least  intcrestingfealurein  the  man- 
ner in  wliich  Dr.  Fen  wick  conveys  instruct  ion.  There 
are  few  book.s  of  this  size  on  practical  medicine  that 
contain  so  much  and  convey  it  so  well  as  the  volume 
before  us  It  is  a  book  we  can  sincerely  recommend 
(o  the  student  for  direct  instruction,  and  to  the  prac- 


f 


titioner  as  a  ready  and  useful  aid  to  his  memory. — 
Am.  Journ.  of  Syphilographij,  Jan.  1S74. 

It  covers  the  ground  of  medical  diagnosisin  a  con- 
cise, practical  manner,  well  calculated  to  assist  the 
student  in  forming  a  correct,  tlioroagh,  and  systpm- 
atic  method  of  examination  and  diagnosis  of  disease. 
The  illustrations  are  numerous,  and  finely  executed. 
Those  illustrative  of  the  microscopic  appearance  o/ 
morbid  tissue,  &c.',  are  especially  clear  and  distinct. 
— Chicago  Med.  Examiner,  Nov.  1J73. 


rfEEEN  ( T.  HENR  Y) ,  M.D., 

^^  Lecturer  on  Pafhology  and  Morbid  Anatomy  at  Charing-Cross  Bospital Medical  School. 

PATHOLOGY  AND  MORBID  ANATOMY.   Second  American, from 

the  Third  and  Enlarged  English  Edition      With  numerousillustrations  on  wood.     In  one 
very  handsome  octavo  volume  of  over  .300  pages,  cloth    $2  75      {Just  Issued.) 


Those  not  acquainted  with  this  text  book  ought  to 
be.  We  have  always  thought  that  for  the  average 
di>ctor  this  work  wa,i  much  more  useful  tlnin  the  larger 
treatises.  Into  it  is  condensed  such  knowledge  to  gain 
which,  elsewhere,  would  require  great  labor  and 
wide  reading.  For  students  and  practitioners  fall 
of  care',  it  is  particularly  Viilnattle.  In  this  edition 
the  general  high  character  of  the  work  is  maintained, 
the  new  cuts  are  fully  up  to  the  standard  of  those 
used  before,  which  were  excellent,  the  execution  of 
the  work  at  the  hands  of  the  publisher  is  fiiuUIess. 
— Chicago  Mfd  Journ.  and  Exam.,  Feb   1S77. 

Altog-^ther.  thisis  the  best  short  manual  of  morbid 
anatomy  in  the  English  language,  and  we  r^-gret  that 


our  space  and  the  character  of  i)ur  contents  forbids  a 
more  extended  notice.  The  arrangement  and  choice 
of  subjects,  the  clearness  and  comparative  thorough- 
ness of  its  statements  make  it  vpry  satisfactory.  We 
are  especially  pleased  with  Ihn  appearance  of  the 
W(.(id  cuti-,  most  of  them  made  for  this  work  after  its 
author's  own  sections  and  drawings,  We  can  only 
repeat  what  we  have  said  before,  that  we  know  of 
notliing  in  the  way  of  a  brief  manual,  superior  to  it 
in  the  English  language.  It  may  be  safely  and  heartily 
commended  to  students,  esppiially  of  ni'irbid  ana- 
tomy.—/o'<rn.  of  Jfervous  and  Mental  Disease,  Oct. 
1S76. 


D 


AVIS  [NATHAN  S.), 

Prof,  of  Principles  and  Practice  of  Medicine,  etc.,  in  Chicago  Med.  College. 

CLINICAL  LECTURES  ON  VARIOUS    IMPORTANT    DISEASES; 

being  a  collection  of  the  Clinical  Lectures  delivered  in  the  Medical  Wards  of  Mercy  Hos- 
pital, Chicago.  Edited  by  Fiiask  H.  Davis,  M.U.  Second  edition,  enlarged.  In  one 
handsome  royal  12mo.  volume.     Cloth,  $1  75.      {Lately  Issued.) 


WHATTO  OBSERVE  ATTHE  BEDSIDE  AND  AFTER 
Death  in  Medical  Cases.  From  the  second  Lon- 
don edition.     1  vol   royal  12mo.,  cloth.    *!  00.         , 

CHRISTISON'S  DISPENSATORY.    With  copious  ad   ' 
ditions.   ■ind  SI.'?  large  wood-nneravinits       By   R 
Emlesfeld  Griffith,  M.  D.    One  vol.  8vo.,  pp.  1000^ 
cloth.    $4  00. 

CARPENTER'S  PRIZE  ESSAY  ON  THE  USE  OI 
Alcoholic  Liquors  in  Health  and  Disea.«e.  New 
edition,  with  a  Preface  by  D.  F.  Condie,  M.D.,  ant" 
explanations  of  scientific  words.  In  one  neat  12mo. 
volume,  pp.  178,  cloth.    60  cents. 

GLUGE'S  ATLAS  OF  PATHOLOGICAL  HISTOLOGY 
Translated,  with  Notes  and  Additions,  by  Jo.^eph 
Leiby,  M.  D.  In  one  volume,  very  large  imperial 
quarto,  with  320  copper-plate  figures,  plain  and 
c  lored,  cloth.     $4  00. 

LA  ROCHE  ON  YELLOW  FEVER,  considered  in  it 
Historical,  Pathological,  Etiological,  and  Therapeo 


tical  Relations.    In  twolarge  and  handsome  octavo 
volumes  of  nearly  1500  pages,  cloth.    $7  00. 

HOLLAND'S  MEDICAL  NOTES  AND  REFLEC- 
TIONS.    1  vol.  8vo.,  pp.  500,  cloth.     %3  ."50. 

BARLOW'S  MANUAL  OF  THE  PRACTICE  OF 
MEDICINE.  With  Additions  by  D.  F.  Condir, 
M    T>      1  vol    0.V0.,  t>T>    600,  cloth       *"  .lO 

TODD'S  CLINICAL  LECTURES  ON  CERTAIN  ACUTB 
Diseases.  In  one  neat  octavo  volume,  of  320  pages 
cloth.    $2  50 

STURGES'S  INTRODUCTION  TO  THE  STUDY  OF 
CLINICAL  JIEDICrXE.  Being  a  Guide  to  the  In- 
vestigation of  Disease.  In  one  haudsome  12mo. 
volume,  cloth,  $1  2.5.     (Lately  I.isned.) 

STOKES'  LECTURES  ON  FEVER  Edited  by  .Torn 
Wir.i.iAM  Mooui-^  M.  D..  Assistant  Physician  to  the 
Cork  Street  Fever  Ho.spital.  In  one  neat  Svo. 
volume,  cloth,  $2  00.     (Just  Is-'iued  ) 


HenryC.  Lea's  Publications — {Practice  of  Medicine). 


15 


WLINT  (AUSTIN),  M.D., 

•*•  Profissor  of  the  Principles  and  Practice  of  Medicine  in  Bellevue  Med.  College,  N.  Y. 

A  TREATISE    ON    THE    PRINCIPLES    AND    PRACTICE    OF 

MEDICINE  ;   designed  for  the  use  of  Students  and  Practitioners  of  Medicine.     Fourth 

edition,  revised  and  enlarged.    In  one  large  and  closely  printed  octavo  volume  of  about  1100 

pp.  ;  cloth,  $6  00  ;  orstrongly  bound  in  leather,  with  raised  bands,  $7  00.    iT.alelij  Issued.) 

By  common  consent  of  the  English  and  American  medical  press,  this  work  has  been  assigned 

to  the  highest  position  as  a  complete  and  compendious  text-book  on  the  most  advanced  condition 

of  medical  science.     At  the  very  moderate  price  at  which  it  is  offered  it  will  be  found  one  of  the 

cheapest  volumes  now  before  the  profession. 

This  excellent  treatise  on  medicine  lias  acquired  ]  dentsand  abook  of  ready  reference  for  practilinners. 
for  itself  in  the  [Tnited  States  a  reputation  similar  to  ]  The  force  of  its  logic,  itH  simple  and  practical  teach- 
that  enjoyed  in  Eugland  by  the  admirable  It'ctures  I  ings,  ha  ve  left  it  without  a  rival  in  the  field — A'.  Y. 
of  Sir  Thomas  Watson.     It  may  not  possess  the  same     Med^  Record,  Sept    I.'),  1874. 
charm  of  style,  but  it  has_  like  .solidity,  the  fruit  of  [      FlinfsPracticeof  Medicine  hasbecome  so  fixed  In 


long  and  patient  observation,  and  presents  liindred 
moderation  and  eclecticism.  We  have  referred  to 
manyof  the  most  i  m  port  ant  chapters,  and  find  there- 
vision  spoken  of  in  the  preface  is  a  genuine  one,  and 
thattheauthor  has  very  fairly  brought  up  his  matter 


itspositionasan  American  textbook  that  little  need 

he  said  beyond  the  announcement  of  a  new  edition. 

It  may,  however,  be  proper  to  say  that  the  author 

has  improved  the  occasion  to  iutrodnce  the  latest 

,    ,.     ,        ,     ,.,     ,  i    .        -...,-  ,  ,  „,      1  contributions  of  medical  literature  together  with  the 

totheleve  oftheknowledgeof  thepresentday.    The    results  of  his  own  continued  clinical  ob.servalions. 

work  has  thisgreat  recommendation,  that  U  IS  in  one  |  Not  so  extended  as  many  of  thp  st^ndaid  works  on 


volume,  and  therefore  will  not  be  so  terrifying  to  the 
student  as  the  bulky  volumes  which  several  of  our 
Enstlish  text-books  of  medicine  have  developed  into. 

—  British  and  Foreign  Med.-Chir.  Rev.,  Jan.  187ft. 

Itisof  course  unnecessary  tointroduce  or  eulogize 
this  now  standard  treatise.  All  the  colleges  rpcom- 
mend  it  as  a  tpxt-book.  and  there  are  few  libraries 
in  which  one  of  its  editions  is  not  to  be  found.  The 
presentedition  hasbeenenlarged  and  revistd  tobring 
it  up  to  the  author's  present  level  of  experience  and 
reading.  His  own  clinical  studies  and  the  latest  con- 
tributions to  mfidicil  literature  both  in  this  country 
and  in  Europe,  have  received  careful  attention,  so 
that  some  portions  have  been  entirely  rewritten,  and 
about  seventy  pages  of  new  matter  have  been  added. 

—  Chicago  M^d   Jintrn.,  June,  1873. 

Has  never  been  surpassed  as  a  text-book  for  stu- 


practice,  it  still  is  sntHciently  complete  for  all  ordi- 
nary reference,  and  we  do  not  know  of  a  more  con- 
venient work  for  the  busy  general  praciiliouer. — 
Cincinnati  Lancet  and  Observer,  June,  lf-73. 

Prof.  Flint,  in  the  fourth  edition  of  his  grew  t  work, 
has  performed  a  labor  reflecting  much  credit  upon 
himself,  a  nd  conferring  a  la  sting  bene  fit  upon  the  pro- 
fession. The  whole  work  shows  evidence  of  thorough 
revision, so  that  it  appears  like  a  new  book  wiitlen 
expressly  for  the  times  For  thegeneral  practitioner 
and  student  of  medicine,  we  cannot  recommeod  the 
bookin  too  strongterms — N.  Y  Mf:d.  Jour  .Sept  '73. 

It  is  gi  vpu  to  very  few  men  to  tread  in  the  steps  of 
Austin  Flint,  whose  single  volume  on  medicine, 
though  here  and  there  defective,  is  a  masterpiece  of 
lucid  condensation  and  of  general  grasp  of  an  enor- 
mously wide  subject. — Lond.  Practitioner,  l>ec.  '73. 


JOT  THE  SAME  AUTHOR. 

ESSAYS    ON    CONSERVATIVE    MEDICINE    AND    KIXDRED 

TOPICS.     In  one  very  handsome  royal  12rao.  volume.     Cloth,  $1  38.     (Just  Issued.) 


H 


■ARTSHORNE  {HENRY),  M.D., 

Professor  of  Hygiene  in  the  Univer.iity  of  Pennsylvania. 

ESSENTIALS  OF  THE  PRINCIPLES  AND 


PRACTICE  OF  MEDI- 


CINE. A  handy-book  for  Students  and  Practitioners.  Fourth  edition,  revised  and  im- 
proved. With  about  one  hundred  illustrations.  In  one  handsome  royal  ]2mo.  volume, 
of  about  550  pages,  cloth,  $2  63  ;  half  bound,  $2  88.     (Lately  Issued.) 


As  a  handbook,  which  clearly  sets  forth  theE.ssEN- 

AI.S  of  thePRl>XlPLE.S  AND  PRACTICE  OF  MEDICINE,  we 

o  not  know  of  its  equal.—  Va.  M^d.  Monthly. 
As  a  brief,  condensed,  but  comprehensive  band- 
book,  it  cannot  be  improved  upon. — Chicago  Med 
E-vaminer,  Nov.  1;'>,  1874. 
The  work  is  brought  fully  up  with  all  the  recent 


advances  in  medicine,  is  admirably  condenspd.  and 
yet  sufficiently  pxplicil  for  all  the  puipoeesiuteuded, 
thus  making  it  by  far  tlie  best  work  of  iis  clinracter 
ever  publislied. —  Oinciinttiti  Clinic,  ^tcl   :H.  1S74. 

Witliout  doubt  the  best  book  of  the  kind  published 
in  the  Engli^h  language. — St.  Louis  Med.  and  Surg. 
Journ.,  Hot.  1874. 


TTT^  TSON  (THOMAS),  31.  D.,  §r. 

LECTURES    ON    THE     PRINCIPLES    AND    PRACTICE    OF 

PHYSIC.  Delivered  at  King's  College,  London.  A  new  American,  from  the  Fifth  re- 
vised and  enlarged  English  edition.  Edited,  with  additions,  and  several  hundred  illus-lra- 
tions,  by  Henry  Hartshorne,  M.D.,  Professor  of  Hygiene  in  the  University  of  PennoylvB- 
nia.  In  two  large  and  handsome 8vo.  vols.  Cloth,  $9  00  ;  leather,  $11  00.  (Lately  Published.) 

It  is  a  subject  for  congratulation  and  for  thankful-  j  rarely  been  equalled,  and  never  surpassed      The  re- 

nessthat  Sir  Thomas  Watson, duringaperiod  of  com-  vision  has  evulenlly  been  mo.st  carefully  di>np,  and 

parative  leisure,   after  a  long,  laborious,  and   most  the  results  appear  in  almost  every  page —firi/.  ifttl. 

honorable  professional  career,  while  retaining  full  /ojtrn.,  Oct.  14,1871. 

possession  of  his  high  mental  faculties,  should  have  q.j,g  author's  rare  combinftllon  of  great  scienttfle 

employed  the  opportunity  to  submit  his  Lectures  lo  attainments  combined  with  wonderful  forenoicelo- 

a  more  thorough  revision  than  was  possible  during  q„ence  has  exerted  extraordinary  influence  over  the 

the  earlier  and   busier  period  of  bis  life.     Carefully  ji^Bt  two  generations  of  physicians.     His  clinical  de- 

passingin  review  some  of  the  most  intricate  and  im-  ^criptiDns  of  most  disoaKPshave  nevei  bpwn  pqualled  ; 

portant  pathological  and  practical  questions,  there-  ^^^  „„  ,jj),j  score  at  team  his  work  will  livn  lon< 

suits  of  his  clear  insight  and  his  calm  judgment  are  j^  ^y^^  future.     The  work  will  be  sought  by  all  who 

now  recorded  for  the  benefit  of  mankind,  in  language  appreciate  a  great  book. — Amer.  Journ.  of  Syphil- 

which,  forprecision,  vigor,  and  classical  elegance,  has  |  ggraphy,  July,  1872. 


16  Henry  C.  Lea's  Publications — (Practice  of  Medicine). 

JDRISTOWE  [JOHN  SYER),  31. D.,  F.K.C.F., 

J-J  Physician  and  Joint  Lecturer  on  Medicine,  St.  Tlioma.<t's  Hospital. 

A  MANUAL  ON  THE  PRACTICE  OF  MEDICINE.    Edited,  with 

Additions,  by  James  H.  Hutchinson,  M.D.,  Pbysicinn  to  the  Penna.  Hospital.  In  one 
handsome  octavo  volume  of  over  1100  pages  :  cloth,  $5  50  ;  leather,  $6  50.  (Just  Read]/.) 
In  the  effort  of  the  author  to  render  this  volume  a  complete  and  trustworthy  guide  for  the 
student  and  practitioner  he  has  covered  a  wider  field  than  is  customary  in  text-books  on  the 
Practice  of  Medicine,  and  has  sedulously  endeavored  to  present  each  subject  in  the  light  of  the 
most  modern  developments  of  observation  and  treatment.  So  much  has  been  done  of  late  years  to 
enlarge  our  knowledge  of  disease  by  improved  methods  of  diagnosis,  and  so  many  new  agencies 
have  been  called  into  service  in  treatment,  that  a  condensed  and  compendious  work,  thoroughly 
on  a  level  with  the  advance  of  medical  science,  can  hardly  fail  to  prove  of  valu«  to  the  profession. 
Dr.  Bristowe  has  loDg  beeu  before  the  profession   |   practitioners  wlio  purchase  few  books  will  find  this 


as  au  a)ile  thiaker  and  writer  on  professional  Rnb- 
jects.  His  present  work  is  second  (o  none  of  its 
liind,  the  part  on  diseases  of  the  nervous  system 
being,  perhaps,  the  most  deserving  of  praise.  It  is 
erninently  readable,  both  in  matter  and  print,  and 
fully  deserves  the  success  it  is  sure  to  obtain. — 
Edin.  Med.  Journ..  Oct.  1S77. 

The  treatment  of  the  various  diseasesisadmirably 
summed  up,  and  we  pronounce  Dr.  Bristowe's  book 
to  be  eminently  practical  on  this  subject.  A  fair 
space  is  given  to  the  dietetics  of  disease,  and  we  are 
glad   that   this  subject  is  receiving  more  and  more 


a  mod  oppoi  time  publication,  becaiase  ^o  many  top- 
ics not  usually  embraced  in  a  work  on  practice  are 
adeq\iaiely  handled.  The  book  is  a  thoroughly  good 
one.  and  its  usefulness  to  American  readers  has  been 
incrensed  by  the  jndijious  notes  of  the  Editor. — 
Uincinnnti  Clinic,  Jan.  7,  1877. 

An  immense  amount  of  information  has  been  com- 
pre>^sed  into  this  volume.  Every  jiage  is  character- 
ized by  tlie  utterances  of  a  thoughtful  man.  While 
we  could  wish  a  fuller  di'-cussiou  and  greater  detail 
in  relation  to  many  subjecos,  we  are  constrained  to 
say  that,  what  has  been  said  has  been  well  said,  and 


attention  in  the  works  on  medicine.     We   give   tlie  |   the  book   is   a   fair   rellex  of  all   that   is  cert'tinly 


author  our  hearty  congratulations,  and  his  book  our 
best  commendations  and  wish  it  all  success. — Lond. 
Med.  Times  and  Gaz.,  Sept.  10,  1877. 


known  ou   the  subjects  considered. — Ohio  Med.  Re- 
corder, Jan.  1877 


.  ,  ,  ,  ,  •'  Upon  the  whole,  we  know  of  no  work  wliich  we 
Anyone  who  wants  a  good,  clear,  condensed  work  eould  more  confidently  recommend  to  the  studentor 
npon  Practice  quite  up  with  the  raostrecentviewsin  j  ,^e  practitioner,  intending  a  review  of  the  field  of 
pathology.will  find  this  a  most  valuable  work.  The  \  t,,g„  j,„j  practice,  than  this  book  of  Dr.  Bris- 
add.tions  made  by  \)v  lluichinson  are  appropriate  i  t^^^.;  ^e  thus  commend  it,  because  the  vast  ar- 
and  nsetul,  and  so  well  done  that  we  wi.sh  there  were  ray  of  facts  pertaining  to  the  practice  of  medicine,  as 
more  ot  them.-^m.  Practitv.ner,  Feb.  18<7.  j  jj  (,  ,o  day.  are  here  presented  ably,  and  with  that 
This  portly  volume  is  a  model  of  condensation,  i  method,  order, and  perspicuity  wliich,  in  all  depart- 
In  a  style  at  once  clear,  interesting,  and  concise.  Dr.  i  ments  of  education,  distinguish  the  lessons  of  an  ac- 
Bristowe  passes  in  review  every  conceivable  subject  i  ceptable  and  profitable  teacher — Chicago  Med. 
connected  with   the   practice   of  medicine.      Those  I  Journ.  and  Examiner,  Aug.  1877. 


H 


AMILTOS'  {ALLAN  McLANE),  M.D., 

Attending  Phi/iicifin  at  the  Ilupittd  for  Epilepticf;  and  PnrnJi/tics.  BlackwelV s  Island,  N.  Y.t 
and  at  the  Out-I'atients'  Department  of  tlie  Nei/>  York  f/oypitnl. 

NERYOUS  DISEASES;  THEIR  DESCPJPTION  AND  TREATMENT. 

In  one  handsome  octavo  volume  of  612  pages,  with  53  illus. ;  cloth,  $3  60.  {Just  Ready.) 
The  object  of  the  author  has  been  to  furnish  to  the  student  and  practitioner  in  a  clear  and 
concise  form  a  guide  to  the  diagnosis  and  treatment  of  affections  of  the  nervous  system,  em- 
bodying the  very  great  advances  made  during  the  last  few  years  in  our  knowledge  of  these  dis 
eases.  Unusual  opportunities  in  public  and  private  practice  have  qualified  him  for  this  work, 
and  his  desire  has  been  to  render  it  strictly  practical,  adapting  it  to  the  wants  not  only  of  the  spe- 
cialist, but  of  the  general  practitioner.  Particular  care  htis  therefore  been  devoted  to  the  manage- 
ment of  nervous  diseases,  and  in  an  appendix  will  be  found  a  careful  selection  of  well-tried  formula). 
The  thorough  manner  in  which  the  subject  hsis  been  treated  may  be  understood  from  the  fol- 
lowing very  condensed 

SUMMARY  OF  CONTENTS. 

Introduction.  Hints  in  regard  to  Examination  and  Study;  Apparatus  for  the  Treatment  of 
Nervous  Disease.  Chap.  I.  Diseases  of  the  Cerebral  Meninges.  Chnp.  II.  to  Chap  VII.  Dis- 
eases of  the  Cerebrum  and  Cerebellum.  Chap.  VII.  Diseases  of  the  Spinal  Meninges.  Chap. 
VIII.  to  Chap.  XII.  Diseases  of  the  Spinal  Cord.  Chap.  XII.  Bulbar  Diseases  Chap.  XIII. 
to  Chap.  XV.  Cerebro-Spinal  Diseases.  Chap.  XV.  Diseases  of  the  Peripheral  Nerves.  Chap. 
XVI.  Neuritis.  Chap.  XVII.  Local  Paralyses.  Chap.  XVIII.  Lead  Poisoning  j  Functional 
Spasm;  Professional  Cramp  :  Formulas. 


riHARCOT  [J.  M.). 

Professor  to  the  Faculty  of  Med.  Paris,  Phys.  to  LaSalpefriire,  etc. 

LECTURES  ON  DISEASES  OF  THE  NERYOUS  SYSTEM.  Trans- 
lated from  the  Second  Edition  by  George  Sigerson,  M.D.,  M.Ch.,  Lecturer  on  Biology, 
etc.,  Cath.  Univ.  of  Ireland.  With  illustrations.  (Publishing  in.  the  Medical  News  and 
Library,  commencing  with  the  July  No.  1878.     See  page  2  ) 


J)TJNOLIS0N,  FORBES,  TWEEDIE,  AND  CONOLLY. 

THE  CYCLOPAEDIA  OF   PRACTICAL  MEDICINE :   comprising 

Treatises  on  the  Nature  and  Treatment  of  Diseases,  Materia  Medica  and  TherapeuticB, 
Diseases  of  Women  and  Children,  Medical  Jurisprudence,  Ac.  Ac.  In  four  large  super-royal 
octavo  volumes,  of  3254  double-columned  pages,  strongly  and  handsomely  bound  in  leather, 
$15;  cloih,  $11. 


Henry  C.  Lea's  Publications — {Practice  of  Medicine). 


n 


JpOTHERGlLL  {J.   MILNER),  M.D.  Edin.,  M.R.C.P.  Lnnd., 

-*■  Asi-f.  Phyn  tn  tliP.  West  Lnnd   Hosp.  ;  Atnt.  Phyn.  to  the  City  of  Lnnd.  ffnup.,  etc. 

THE  PRACTITIONER'S  HANDBOOK  OF  TREATMENT;  Or,  the 

Principles  of  Therapeutics.     In  one  very  neat  octavo  volume  of  about  550  pages  :  cloth, 
$4  00.      {Noiv  Ready.) 

It  may  be  said  that  the  scope  of  this  work  i.s  not  dissimilar  to  that  of  the  well  known 
"Principles  of  Medicine,"  by  Dr  J.  C.  B.  Williams,  now  long  out  of  print,  which  in  its  day 
met  with  such  unusual  acceptance.  More  practical  in  its  character,  however,  it  .=eeks  to  bring 
to  the  aid  and  elucidation  of  positive  therapeutics,  the  vast  accumul.'ition  of  scientific  facts  and 
theories  made  by  the  present  generation,  pointing  out  the  measures  to  be  adopted  nt  the  bedside 
and  establishing  them  on  firm  rational  grounds.  Such  a  work,  by  a  first-iate  man,  and  fully 
up  to  the  advanced  condition  of  science,  cannot  fail  to  prove  of  the  utmost  service  to  both 
student  and  practitioner. 


Our  friends  will  lincl  tills  a  very  ruailable  book;  atui 
that  it  sheds  lighi  uvon  every  theme  it  touches, cau.'-iiiif 
the  practitioner  to  feel  more  cerrain  of  his  diaf^nosis  in 
ditticult  ca.«es.  We  confidently  curaniend  the  work  to 
our  readers  as  one  worthy  of  careful  peru.xal.  ]t  liirhis 
the  way  over  obscure  aTid  difficult  pa-^ses  in  meiiical 
practice.  The  chapter  on  the  circulation  of  the  blood 
is  the  most  exhaustive  and  instructive  to  be  found.  It 
is  a  book  every  practitioner  needs,  and  would  have,  if 
he  knew  how  sutfij^stive  and  helpful  it  would  be  to 
him.— iV.  Louis  Med.  and  Surg.  Jour 't.,  A;;ril,  1877. 

The  object  is  one  of  the  most  important  wliicn  a  med- 
ical writer  can  propose  to  himself,  for  therapeutics  is  the 
goal  of  medicine,  and  the  plan  is  an  excellent  one.  In 
justice  to  Dr.  Fothergill  we  ought  to  say  that  he  has  ad- 
hered to  his  plan  throughout  the  work  with  fidelity,  and 
has  accomplished  his  object  with  a  rare  degree  of  success. 
We  heartily  commend  bis  book  to  the  medical  student 
as  an  honest  and  iutelliijent  guide  through  the  mazes  of 
therapeutics,  aud  assure  the  practitioner  who  has  grown 
gray  in  the  harness  that  be  will  derive  pleasure  aud  in- 
struction from  its  perusal  The  imperfections  and 
errors  which  we  have  noticed  are  few  aud  unimportant. 
On  the  ether  hand,  the  excellences  are  many  ^nd  patent. 
Valuable  suggestions  and  material  for  thought  abound 
throughout.  The  chapters  on  body  heat  and  fever,  in- 
flammation, action  and  inaction,  and  the  luinary  .sys- 
tem are  particularly  good.  The  descriptions  of  patho- 
logical conditions,  and  the  character  of  the  therapeutic 
Baeasures  advised  give  evidence  of  sound  clinical  obser- 
vation.- Boston  Med.  and  Surg  Journal,  Mar  8,  1877. 

The  strong  good  sense,  the  racy  style,  the  practical 
onaracter  of  his  instruction,  are  qualities  in  the  author 
Which  commend  him  to  American  physicians.     In  the 


volume  before  us  Dr.  FothergjU  appears  in  his  best 
mood.  Our  readers,  especially  the  jounger  members  of 
the  profession,  will  find  this  a  most  suggestive  ai.d  Urc- 
ful  book.  There  are  few  old  practitioners  who  will  not 
be  benefiltd  by  its  peru.sal.  We  coniniend  it  to  all 
classes  of  readers,  with  theexpression  of  belief  that  those 
who  buy  it  will  be  hardly  content  to  doge  it  until  the 
last  leaf  is  turned  over.— C'ncoina/!  Clinic,  .Mar  it,  1S77. 

It  is  our  honest  conviction,  after  a  careful  perusal  of 
this  goodly  octavo,  that  it  represents  a  great  amount  of 
earnest  thought  and  painstaking  work,  and  is  therefore 
one  of  those  books  which  both  deserve  and  are  likely  to 
survive.  This  book,  although  written  ostensibly  lor  the 
young  and  inexperienced,  may  be  very  profitably  studieil 
by  those  who  have  been  practising  their  profession 
more  or  less  empirically  for  thirty  or  forty  years.  We 
particularly  reeonmiend  ihe  diapters  on  I'uMic  and 
Private  Hygiene.  Kood  in  Health  and  Ill-Health,  and 
the  Conclusion— the  Medical  Man  at  the  lied.-ide  The 
last  is  high-toned,  and  indicates  much  shrewdnessol  ob- 
servation. Our  hi  ace  will  not  adni  i  t  of  further  quotai  ion. 
We  content  ourselves  with  again  recommending  the 
book  very  cordially — Edin.  Med.  Journ.,  .)an   1^77. 

It  isof  great  advantage  to  the  practitioner  to  have  gen- 
eral principles  to  guide  him,  and  that  he  should  not, 
when  confronted  with  an  asseuiblage  of  pnlliologioal 
symptoms,  be  at  the  mercy  of  an  unreasoned  experienco 
of  a  similar  case,  or  be  obliged  to  swear  in  verlpi  mugistri. 
He  will  find  reasons  in  this  work  for  not  looking  upon 
drugs  as  grouped  in  fixed  and  unalteralile  categories, 
but  learn  when  and  why  he  may  give  opium  to  cause 
purgation,  and  castor  oil  to  check  it.  We  strongly  re- 
ci'ramend  it  to  our  readers. — The.  London  Prw.tttioner, 
Jan.  1877. 


^By  the  same  Author. 

THE  ANTAGONISM  OF  THERAPEUTIC  AGENTS,  AND  WHAT 

IT  TEACHES.     Being  the  Fothergillian  Prize  Essay  for  1878.     In  one  neat  volume,  royal 
12mo.  of  about  200  pages.      {tShortli/.) 
It  would  seem  unnecessary  to  call  the  attention  of  the  profession  to  a  work  on  so  suggestive  a 
nibject  by  a  writer  so  brilliant  as  Dr.   Fothergill.     There  is,  perhaps,  no  one  who  has  a  better 
ilaim  to  be  heard,  and  no  topic  more  worthy  the  study  and  reflection  of  the  practitioner. 


T  TNCOLN  [D.  P.),  31. D., 

^  Physician  to  the.  Department  of  Nervous  Disea.ies,  Boston  Dispensary. 

ELECTRO-THERAPEUTICS;  A.  Concise  Manual  of  Medical  Electri- 
city.    Inoneveryneatroyall2mo.  volume, cloth,  withillustrations,  $1  60.     {Just  Issued.) 


A 


DOBERTS  (  WILLIAM),  M.  D., 

Lecturer  on  Medicine  in  the  Manchester  School  of  Medieint,  Ac. 

PRACTICAL  TREATISE    ON  URINARY  AND    RENAL    DI8- 

EASES,  including  Urinary  Deposits.  Illustrated  by  numerous  oases  and  entrravingo.  Sec- 
ond American,  from  the  Second  Revised  and  Enlarged  London  E<lition.  Id  one  large 
and  handsome  octavo  volume  of  61fi  pages,  with  a  colored  plate  ;  cloth,  $4  50.     (Latfly 

Piihtished.) 


ECTDRES  ON  THE  STUDY  OF  FEVER.      By  A.  |  NERVOHS  DISORnER."?     RvC.  HA!«nriKi.n  Jowii.i 

HPDSON    M.D     M.R.I  A.,  Physician  to  the  Meath  ,  M.D.,  Physlci*n  to  St.   Mary'^  Hospltnl,  fte.     Seo 

Hospital.     In  one  vol   8ro.,  cloth,  *2.'i0.  end    American  Edilb.u      I  n  .Mie  haDdnome  ocIh  vo 

TREATISE  ON  FEVER.      By  Robkrt  D.  Lto.n8,  '  '"'"««  "f  ^»'*  l'"*-"'  "'■"»'•  *"^  ■-•''                       ' 
K  C  C.     In  one  octavo  volume  of  363  pages,  cloth,    baSHAM  ON  RENAL  DISEASES:  a  CllnicBl  Onlde 

*2  25.                                                                                      j  to  their  DiacDOr'U  And  TrPHlmenl,     With   lllnslra- 

1.INICAL    OBSERVATIONS    ON    FUNCTIONAL  tious.     In  one  12mo.  vol.  of  30»  pages.cloih   ♦2  00. 


18 


Henry  C.  Lea's  Publications — {Diseases  of  the  Chest,  dbc). 


J^LINT  (AUSTIN),  M.D., 

-*•  Prnfessor  of  the  Principlex  and  Practice  of  Medicine  in  Selhvue  Hospital  Med.  College,  N.  T. 

PHTHISIS:  ITS  MORBID  ANATOMY,  ETIOLOGY,  SYMPTOM- 
ATIC EVENTS    AND    COMPLICATIONS,  FATALITY   AND   PROGNOSIS,  TREAT- 
MENT,  AND   PHYSICAL  DIAGNOSIS:    in  a  series  of  Clinical  Studies.     By  Austin 
Flint,  M.D.,  Prof,  of  the  Principles  and  Practice  of  Medicine  in  Bellevue  Hispital  Med. 
College.  New  York.     In  one  handsome  octavo  volume:  $3  50.      {Lately  Issued.) 
This  volume,  containing  the  results  of  the  author's  extended  observation  and  experience  on  a 
subject  of  prime  importance,  cannot  but  have  a  claim  upon  the  attention  of  every  practitioner. 
This  book  contains  rin  Kna!.v?i?.  in  tlie  autliovV  lucid  i    litioner.    While  the  author  tiikp?  i^sue  wiUi  many  of  the 
style,  of  the  notes  which  he  lisis  made  in  several  hun-  |   leadiiiL' niinUii  of  Iheihiy  on  impiinaiitque.'tion.«  arising 


dred  ca^^es  in  hospital  and  private  practice.  We  com 
mend  tlie  book  to  the  )iernsal  of  all  interested  in  the 
study  of  tin's  disease. — Boston  Med.  and  Surg  Journal, 
Feb  "10.  1876. 

The  name  of  the  author  is  a  suffcient  frnarantepthat. 
this  book  is  of  practical  value  to  both  ,«tudent  and  jirac- 


in  the  study  of  phthisis,  the  stronu  testimony  of  expe- 
rience and  authority  will  liuve  i;rent  weiuhl;  with  the 
seeker  after  truth.  As  the  result  of  diniciil  .^tudy.  the 
■work  is  unequalled. — SI.  Louis  Med.  and  Surg  Journal, 
.March,  187  b. 


j^T  THE  SAME   AUTHOR.    (Just  T-tnued.) 

A  MANUAL    OF  PERCUSSION  AND    AUSCULTATION;    of  the 

Physical  Diagnosis  of  Diseases  of  the  Lungs  and  Heart,  and  of  Thoracic  Aneurism.     In 

one  handsome  royal  12mo.  volume:  cloth,  $1  75. 
In  this  little  work  the  object  of  the  author  has  been  to  present  in  a  clear  and   compact  form 
the  existing  condition  of  physical  exploration,  showing  the  manner  of  conducting  it  and  the 
diagnostic  value  of  the  several  signs  thereby  elicited. 

We  can  cocfiJently  recoraraeod  this  treatise  to  all    I   rightly  valne  these  modes  of  exploration  of  disease.  Bi 
who  would  learn  auscultation  aad  percussion,  aad    |  — British  und  For.  Med.-Cliir   iJer.,  July,  1877.  **' 


T>Y  THE  SAME  AUTHOR. 

A  PRACTICAL  TREATISE  ON  THE  DIAGNOSIS,  PATHOLOGY, 

AND  TREATMENT  OF  DISEASES  OF  THE  HEART.     Second  revised  and  enlarged 

edition.     In  one  octavo  volume  of  550  pages,  with  a  plate,  cloth,  $4. 

Dr.  Flint  chuse  a  difficult  subject  for  his  researches,    ind  clearest  practical  treatise  on  those  subjects,  and 

&nd  has  Khown  remarkable  powers  of  observation     (honld  he  in  the  hands  of  all  practitioners  and  st-i- 

and  reflection,  as  well  as  great  industry,  in  his  treat-     lents.    It  is  a  credit  to  American  medical  literature 

mem  of  it.    Uis  book  must  be  considered  the  fullest :  -Amer.  Journ.  of  the  Med.  Sciences,  July,  1860. 

T)T  THE  SAME  AUTHOR. 

A   PRACTICAL    TREATISE   ON    THE   PHYSICAL   EXPLORA- 
TION OF  THE  CHEST  AND  THE  DIAGNOSIS  OF  DISEASES   AFFECTING   TEE 
RESPIRATORY  ORGANS.    Second  and  revised  edition.    In  one  handsome  octavo  volume 
of  595  pages,  cloth,  $4  50. 
Dr.  Flint's  treatise  is  one  of  the  most  trustworthy]  incy  to  over-refinement  and  unnecessary  miuuieness 
guides  which  we  can  consult.    The  style  is  clear  and    vhich  characterizes  many  works  on  the  same  sub- 
distinct,  andis  also  concise,  beingfree  from  that  tend- Iject. — Dublin  Medical  Press,  Feb.  6,  1867. 


W' 


7LLIAMS  (C. ./.  B.),  M.D., 

Senior  Gonsuliing  Physician  to  the  Hospital  for  Consumption,  Brompton. 

PULMONARY  CONSUMPTION;  Its  Nature,  Varieties,  and  Treat- 
ment. With  an  Analysis  of  One  Thousand  Cases  to  exemplify  its  duration.  In  one  neat 
octavo  volume  of  about  350  pages,  cloth,  $2  50.     (Lately  Published.) 


O 


'HAMBERS  (T.  K.),  M.D., 

Consulting  PhysU-inn  to  St.  Mary's  Hospital ,  London,  &c. 

A  MANUAL  OF  DIET  AND  REGIMEN  IN  HEALTH  AND  SICK- 

NESS.     In  one  handsome  octavo  volume.     Cloth,  $2  75.       (Jiist  Issued.) 


DIPHTHERIA;  its  Nature  and  Treat -nent,  with  an  ! 
account  of  the  History  of  its  Prevalence  in  vari- 
ous Countries.    By  D    D  St,.fDF.,  M.D.    Second  and 
revised  edition.    In  one  neat  royal  12mo.  volume, 
cloth,  .$1  2.5. 

WALSHE  ON  THE  DISEASES  OF  THE  HEART  AKT 
GREAT  VESSELS.  Third  American  edition.  In 
1  vol.  8vo..  4?.n  T>p..  cloth      *S  00 

FULLER  ON  DISE.ASES  OF  THE  LUNGS  AND  AIR- 
PASSAGES.  Their  Pathology,  Physical  Diagnosis. 
SymptoniK,  and  Treatment.  From  the  second  and 
revised  English  edition.  In  one  handsome  octavo 
voltirae  of  about  .oOO  pages  :  cloth,  $;5  HO. 

LA  ROCHE  ON  PNEUMONIA.  1  vol.  Svo.,  cloth, 
of  500  pages      Price  $:?  00. 

SMITH  ON  CONSUMPTION;  ITS  EARLY  AND  RE- 
MEDIABLE STAGES.     1  vol.  Svo. ,  pp.  254.    $2  26. 


LECTURES  ON  THE  DISEAiSES  OF  THE  STOMACH. 
With  an  Introduction  on  its  ABafomy  and  Physio- 
logy. By  VViM.i.AM  Brtntox,  M  D..  F  R  S  Fri'iu 
the  second  and  enlarged  London  edition .  With  il- 
lustrations on  wood.  In  one  hand.-^ome  octavo 
volume  of  about  ;^00  pages:  cloth,  W  2£. 

CHAMBERS'S  RESTORATIVE  MEDICINE.    An  H;)i 
veian    Anaual  Oration.     With  Two   Sequels.     In     , 
one  very  handsome  vol.  small  12ino  ,  ct'ilh,  $1  00.    f 

PAVY'S  TREAT;SE  ON  THE  FUNCTION  OF  DI-  I 
GESTION;  its  Disorders  and  their  Treatment  . 
From  the  second  London  edition.  In  otie  hand*  U 
some  volume,  small  octa^'o,  cloth.  %2  00.  il 

PAVY'S  TREATISE  ON  FOOD  AND  DIETETICS. 
Physiologically  and  TherapenticaUy  Consi.iered. 
In  one  handsome  octavo  volume  of  nearly  tiOO 
pages,  cloth,  ijsl  75. 


Henry  C.  Lea's  Publications — (  Venereal  Diseases,  (ho.).  19 


J>nMSTEAD  {FREEMAN  J.),  M.D., 

-*-'         Professrir  of  Venerenl  Diaeasea  at  the  Col.  of  Phys.  and  Hurg.,  New  Tork,  &c. 

THE   PATHOLOGY   AND   TREATMENT   OF   VENEREAL   DIS- 
EASES.    Including  the  results  of  recent  investigations  upon  the  subject.     Third  edition, 
revised  and  enlarged,  with  illustrations.     In  one  large  and  handsome  octavo  volume  of 
over  700  pages,  cloth,  $5  00  ;  leather,  $6  00. 
In  preparing  this  standard  work  again  for  the  press,  the  author  h;is  subjected  it  to  a  very 
thorough  revision.    Many  portions  have  been  rewritten,  and  much  new  mutter  added,  in  order  to 
bring  it  completely  on  a  level  with  the  most  advanced  condition  of  syphilograpliy,  but  by  careful 
compression  of  the  test  of  previous  editions,  the  work  has  been  increased  by  only  "si.tty-four  pages. 
The  labor  thus  bestowed  upon  it,  it  is  hoped,  will  insure  for  it  a  continuance  of  its  position  as  a 
complete  and  trustworthy  guide  for  the  practitioner. 

A  valuable  work  on  Venereal  Diseases,  which  not 
only  has  a  wide  circulation  in  thi.s  country,  aud 
hfen  accepted  as  the  standard,  but  appear.s  to  Im  ve 


formed  tlie  ba.sis,  to  a  lar^e  extent,  of  many  of  the 
l)Ook.s  and  articles  which  Imve  been  written  on  the 
same  subject  and  pnblishpd  in  England.-  The  Glas- 
gow Mt"1.  Jcmrn,.  Oct.  1S77. 

It  IS  the  most  complete  book  with  which  we  are  ac- 
laainted  in  the  language.  The  latest  views  of  the 
lest  authorities  are  put  forward,  and  the  information 
is  well  arranged — a  great  point  for  the  student,  and 
still  more  for  ihe  practitioner.  The  subjects  of  vis- 
leral  syphilis,  syphilitic  affections  of  tiie  eyes,  and 
the  treatment  of  syphilis  by  repeatedinoculatious.  are 
very  fully  discussed. — London  Lancet,  Jan.  7,  1871. 

Dr.   Bumstead's   work   is   already  so  universally 
mown  as  the  best  treatise  in  the  English  language  on 


(lULLERIER  [A.],  and 

'-''         Siirgeo'ii  to  the  Hdpital  du  Midi. 


venereal  diseases,  that  it  may  seem  almost  superDn- 
ona  to  say  more  of  it  than  that  a  new  edition  has  been 
issued.  But  the  author's  indnsnv  has  rendered  this 
n«!w  edition  virtually  a  new  work, and  so  merits  as 
much  special  coramendiitiou  as  if  its  predecessors  had 
not  been  published.  As  a  thoroughly  practical  book 
on  a  class  of  diseases  which  form  a  large  share  of 
nearly  every  physician's  practice,  the  volume  before 
us  is  bv  far  the  best  of  which  we  have  knowledge. — 
N.  Y.  Medical  Gazette.  Jan.  28,  1871. 

It  is  rare  in  the  history  of  medicine  to  find  any  one 
book  which  contains  all'  that  a  practitioner  needs  to 
know;  while  the  posspssor  of  "Bum^tead  on  Vene- 
real" has  uo  occasion  to  look  outside  of  its  covers  tor 
anything  practical  connected  with  the  diagnosis,  his- 
tory, or  treatment  of  these  affections.— iV.  Y  Medical 
Journal.  March,  J 871. 


jyUMSTEAD  (FREEMAN  J.). 

-'-'        Pro/es.ior  of  Venert-al  Di.wi.ie.'.-  in  the  College  uf 
Phy.<!icin»/i  and  SvrgeonK.  N    Y 

AN  ATLAS  OF  VENEREAL  DISEASES.     Translated  and  Edited  by 

Freeman  J.  Bumstead.     In  one  large  imperial  4to.  volume  of  328  pages,  double-columns, 

with  26  plates,  containing  about  150  figures,  beautifully  colored,  many  of  them  the  size  of 

life;  strongly  bound  in  cloth,  $17  00  ;   also,  in  five  parts,  stout  wrappers,  at  $-3  per  part. 

Anticipating  a  very  large  sale  for  this  work,  it  is  offered  at  the  very  low  price  of  Three  Dol- 

ARS  a  Part,  thus  placing  it  within  the  reach  of  all  who  are  interested  in  this  department  of  prao- 

ice.     Gentlemen  desiring  early  impressions  of  the  plates  would  do  well  to  order  it  without  delay . 

A  specimen  of  the  plates  and  text  sent  free  bj'  mail,  on  receipt  of  2.5  cents. 

We  wish  for  once  that  our  province  was  not  re.strict-    to  its  end,  we  do  not  know  a  single  medical  work, 


d  to  methods  of  treatment,  that  we  might  say  some- 

hing  of  the  exquisite  colored  plates  in  this  volume. 

-London  Practitioner,  May,  1869. 
As  a  whole,  it  teaches  all  that  can  be  taught  by 
eans  of  plates  and  print. — London  Lancet.  March 

3,  1S6S. 
Superior  to  anything  of  the  kind  ever  before  issued 

n  this  contiuont, — Canada  Med.  Journal.  Marrh,  '(iO. 
The  practitioner  who  desires  to  understand  this 
ranch  of  medicine  thoroughly  should  olilaio  this, 
e  most  complete  and  best  work  ever  published. — 
'dminion  Med.  Journal,  May,  1869. 
This  is  a  work  of  master  hands  on  both  .sides.  M 
uUerieris  scarcely  second  to,  we  think  we  may  truly 
ly  is  a  peer  of  the  illustrious  and  venerable  Ricord, 
hile  in  this  country  we  do  not  hesitate  to  say  that 
r.  Bumstead,  as  an  authority,  is  without  a  rival 
asuring  our  readers  that  these  illustrations  tell  the 
hole  history  of  venereal  disease,  from  its  inception 


tvhich  for  its  kind  is  more  necejixary  for  them  to  have. 
—  California  Med.  Gazette.  March.  1869. 

The  most  splendidly  illustrated  work  in  the  Ian 
(fuagp,  and  in  our  opinion  far  more  useful  than  the 
French  original  —^m.  Journ.  Med.  SiienceD,  Jan.  6i-. 

The  fifth  and  concluding  number  of  this  m«gnificenl 
work  has  reached  us,  and  we  have  no  hesitation  in 
saying  that  its  illustration-  surpass  those  of  previous 
anmhevH.  — Bo.tt  Med  and  Hnr(j  ./'..Jan.  14    186ft. 

Other  writers  besides  M.  Cnllerier  have  given  ns  a 
good  account  of  the  diseases  of  which  he  treats,  bul 
no  oue  has  furnished  us  with  such  a  complete  series 
of  illustrations  of  the  venereal  diseases  Tliere  i^ 
however,  an  additional  interest  and  value  possessed 
by  the  volume  before  us  ;  f.)r  it  is  au  American  reprint 
and  translation  of  M.  Onllorior's  work,  with  inci- 
dental remarks  by  onenf  th<'  most  eminent  American 
syphi'ographers,  Mr  Bumstead. — Brit,  and  For. 
Medioo-Chir.  Review.  Jul  v.  1  SHO 


EE  [HENRY), 

Prof,  of  Surgery  at  the  Rnijal  College  of  Snrgeonn  of  England,  etc. 

LECTURES  OX  SYPHILIS  AND  OX  SO.ME  FORMS  OF  LOCAL 

DISEASE  AFFECTINtJ  PRINCIPALLY  TIIE  ORGANS  OF  GENERATION.     In  one 

handsome  octavo  volume:  cloth;  $2  25.  (Latch/  Pithlisked.) 

iThe  work   is  valuable,  as  it  treats  quite  fully  of  sub  Min.lit,.-a-ioi,s  of  these  processes  in  pntleti'"  Previously 

T.ts  which  are  not  clw<.lt  upon  iu  the  systematic  works  -vpbilitio:  primary  ami  s.M-on.tnrv  synhihtir  .iismses  of 

iotherJ:n}rlishauthorsofthepro.'!entday.astheinoc  the  mucous  membranes  nii.l  their  l"«»>il>l.v    <>. '•"«""'«';. 

labilitynf  syphilitic  blood:  the  conditions  under  which  iii''.'le  constitutumiil  svphili-.  etc     1  lie  book  is  Hi  I  ol 

lesecretiousofprimaryand  secondary  syphilitic  man-  clinical   mntprial   illustrRli.u'  those  topu-s.  or.Kluhl    or 

Ifltations  may  be  inoculated  naturally  or  artificially :  quoted.— 4rc/.i»e«  o//Vr;H«/"^<;.V.  April,  18.6. 
Ipimorbid  processes  produced  by  such  inoculation;  tlie 


ILL  (BERKELEY), 

Surgeon  to  the  Lock  Hoxpital,  London. 

ON  SYPHILIS  AND  LOCAL 


CONTAGIOUS  DISORDERS.     In 


one  handsome  octavo  volume  ;  cloth,  $.3  25. 


20 


HfiNRY  C.  Lea's  Publications — (Diseases  of  the  Skin,  &c.). 


pox  [TILBURY],  M.D.,F.R.C. P.,  and  T.  C.  FOX,  B.A.,  M.R.C.S., 

-*-  Phyfticirin  to  the  Department  for  Skin  Diseagefi,  Univermtp  Colli ge  l/of,}4lnl. 

EPITOME  ,0F  SKIN  DISEASES.     WITH  FORMULA.     For  Stu- 


DENTS    AND    PRACTITIONERS 

(Just  Issued.) 

A  very  clear  and  concise  description  is  piven  of  the 
elementary  lesions  and  the  author's  remarks  on  the 
geiiiral  character,  complications,  and  modifications  of 
eruptions.  tojTHther  ■nith  their  practical  hints  on  the  ex- 
amination of  skin  diseases,  will  he  of  great  assistance 
to  the  novice  in  this  department  of  medicine.  We  know 
of  no  other  which,  in  so  little  space,  contains  so  much 
reliable  informatiim.— iV.  I'.  A/ed.  Jmirn.,  Dee.  1876. 

It  has  no  especial  features  other  than  it  is  concise  and 
quite  practical.  The  early  chaptens,  treating  of  ele- 
mentary matters,  in  the  study  of  skin  diseases,  are  very 
good,  and  the  list  of  formulae  is  excellent.— .<l)'c/iij)e.io/ 
Clinical  Surffe.y.  Dec.  1876. 

If  doctors  nei;lect  the  study  of  diseases  of  the  skin,  it 
will  not  be  forlack  of  opportunities  of  instruction.  This 
little  handbook  contains  wonderfully  condensed  know- 
ledgce  that  cannot  but  be  most  useful  to  every  one  who 
will  read  it.— American  Practit'om',  Jan  1877. 

This  little  work  cannot  fail  to  ncciuire  a  lart;c  circle  of 
readers.  In  a  very  small  compass  all  the  essential 
points  of  the  cla.ssification,  diagnosis,  symptoms,  and 


In  one  handsome  12mo.  volume,  of  120  pages  :  cloth,  $\. 


treatment  of  skin  diseases  are  accurately  and  completely 
stated  without  beini;  cramjied.  The  hook  is  so  well  ar- 
r.anv;ed  that  the  reader  will  have  no  ditliculty  in  finding 
at  once  exactly  the  information  he  may  reiiuire.  A 
carefully  compiled  formulary  of  remedies  for  skin  affec- 
tions and  some  notes  on  diet  in  skin  diseases,  cojisidera- 
hly  enhance  the  value  of  the  epitome. — London  LancetA 
Nov.  4,  1876. 

It  must  be  admitted  that  even  those  well  prepared  for| 
genera!  practice  l3nd  diseases  of  the  skin  difficult  of  cla-s-, 
sificatiin.  and  as  difficult  of  diagnosis,  and  that  nothing 
is  more  desirable  than  some  work  which,  not  elaborate 
in  nature,  shall  be  a  useful  ordinary  guide,  iind  issued 
bv  some  one  of  recognized  authority.  It  is  believed  thatj 
this  manuiil  of  Tilbury  Fox  and  T.  C.  Fox  exactly  meets 
the  wants  indicated.  It  epitomizes,  in  a  very  short  i 
pass,  the  clinical  features  in  the  treatment  of  diseases 
of  the  skin.  The  volume  i«  so  small  that  it  can  be  carl 
ried  in  the  pocket,  while  the  text  furnishes  briefly,  but 
clearly,  the  information  desired  by  the  general  practin 
tioner.  It  meets  fully  an  almost  universal  want. —  Ami 
j5(-H«7y,  Jan.  6,1877. 


JY^^^SON  { ERA SMUS),  F.R. S. 

ON  DISEASES  OF  THE  SKIN.     With  Illustrations  on  wood.    Sev^ 

enth  American,  from  the  sixth  and  enlarged  English  edition.     In  one  large  octavo  volum* 
of  over  800  pages,  $5. 

A  SERIES   OF   PLATES   ILLUSTRATING  "WILSON   ON   DIS| 

EASES  OP  THE  SKIN;"  consisting  of  twenty  beautifully  executed  plates,  of  which  thiM 
teen  are  exquisitely  colored,  presenting  the  Normal  Anatomy  and  Pathology  of  the  SkinJ 
and  embracing  accurate  representations  of  about  one  hundred  varieties  of  disease,  most  ol 
them  the  size  of  nature.  Price,  in  extra  cloth,  $5  50. 
Also,  the  Text  and  Plates,  bound  in  one  handsome  volume.  Cloth,  $10. 
^y  THE  SAME  AlTTHOH.  

THE  STUDENT'S  BOOK  OF  CUTANEOUS  MEDICINE  and  Disj 

BASES  OF  THE  SKIN.    In  One  Very  handsome  foyal  I2mo.  volume.    $3  50. 

J^ELIGAN  [J.  MOORE),  M.D.,  M.R.I. A. 

ATLAS    OF  CUTANEOUS  DISEASES.      In  one  beautiful  quart 

volume,  with  exquisitely  colored  plates,  &c.,  presenting  about  one  hundred  varieties 
disease.     Cloth,  $5  50. 
The  diMgaosis  of  eiuptive  disease,  however,  under 


all  circumstances,  is  very  difficult.  Nevertheless, 
Dr.  Neligan  has  certainly,  "as  far  as  possible,"  given 
a  faithful  and  accurate. representation  of  this  class  of 
diseases,  and  there  can  he  no  doubt  that  these  plates 
will  be  of  great  use  to  the  student  and  practitioner  in 
drawing  a  diagnosis  as  to  the  class,  order,  and  species 


to  which  the  particular  case  may  belong.  WhiU 
coking  over  the  "Atlas"  we  have  been  induced  tc 
'Xaniiue  also  the  "Practical  Treatise."  and  we  ar« 
inclined  to  consider  it  a  very  superior  work,  coii.ij 
bining  accurate  verbal  description  with  sound  viewl 
of  the  pathology  and  treatment  of  eruptive  di8eaae( 
—  Gln.sgow  Med.  Journal. 


JJILLIER  [THOMAS),  M.D., 

Phy.ncian  to  the  Skin  Department  of  Univemity  Qollege  Hospital,  &c. 

HAND-BOOK  OF  SKIN  DISEASES,  for  Students  and  Practitioners. 

Second  Am.  Ed.     In  one  royal  12mo.  vol.  of  358  pp.     With  Illustrations      Cloth,  $2  25. 

We  can  con.scieutiously  recommend  it  to  the  stu-  It  is  a  concise,  plain,  practical  treatise  on  the  varl- 

aent ;   the  style  is  clear  and  pleasant  to  read,  the  ous  diseases  of  the  skin  ;  just  such  a  work,  indeed, 

maaer  IS  good,  and  the  descriptions  of  disease,  with  as  was  much  neede.i,  both  by,  medical  stadent-s  and 

ttiemodesof  treatment  recommended,  are  frequently  practitioners. —  CAtcaao   Medical  Examiner,   May, 

Illustrated  with  well-recorded  cases.— iondoTi  Med.  186.5. 
Time.'<  and  Gazette.  April  1,  186.') 


^MITH  [E  USTA  CE).  M.  D., 

Physician  to  the  Northwest  London  Free  Dispensary  for  Sick  Children. 

A  PRACTICAL  TREATISE  ON   THE  WASTING   DISEASES  0. 

INFANCY  AND  CHILDHOOD.  Second  American,  from  the  second  revised  and  enlargei 
English  edition.  In  one  handsome  octavo  volume,  cloth,  $2  50.  (Lately  Issued.) 
This  IB  in  every  way  an  admirable  book.  The 
modest  title  which  t  he  author  has  chosen  for  i  t  scarce- 
ly conveys  an  adequate  idea  of  the  many  tubjects 
upon  which  it  treats.  Wasting  is  ^o  constant  an  at- 
tendant upon  the  maladies  of  childhood,  that  a  trea- 


tise npon  the  wasting  diseases  of  children  must  neces 
STily  embrace  the  consideration  of  many  affections 
of  which  it  is  a  symptom  ;  and  this  is  excellently  well 
done   by  Dr.  Smith.    The  book  might  fairly  be  de- 


scribed as  a  practical  handbook  of  the  common  dis- 
eases ofchildren,  so  numerous  are  the  affections  con- 
sidered   either    collaterally  or    directly       We    are 
acquainted  with  no  safer  guide  to  the  treatment  of  1 
children's  diseases,  and  few  works  give  the  insighijll 
into  the  physiological  and  other  peculiarities  of  chil'-' 
dren  that  Dr.  Smith's  book  does. —firi7.  Med.Journ., 
April  8,  1871. 


Henry  C.  Lea's  Publications— <' Diseases  of  nhildren, 


21 


8' 


IMITHiJ.  LEWIS),  M.  D., 

Professor  of  Morbid  Anatomy  in  the  BelU.vue  Honpitnl  Med    College,  N   T. 

A  COMPLETE  PRACTICAL  TREATISE  0\  THE  DISEASES  OP 

^?r,^fl^^^^'     '^^^^'^  Edition,  revised  and  enlarged.      In  one  handsome  octav.    volume 
of  726  pages.    Cloth,  $5  ;  leather,  $6.      (Just  Issued.) 

The  eminent  success  which  this  work  has  achieved  has  en"ourage<l  the  author,  in  prep.iring 
this  third  edition,  to  render  it  even  more  worthy  thiin  heretofore  of  the  f.ivor  .,f  the  profession. 
It  has  been  thoroughly  revised,  and  very  considerable  additions  have  been  made  throughout. 
To  accommodate  these  the  volume  has  been  printed  in  a  smaller  type,  so  as  to  prevent  any 
notable  increase  in  its  size,  and  it  is  pre.sented  in  the  hope  that  it  may  attain  the  position  of 
the  American  text  book  on  this  important  department  of  medical  science. 


This  work  took  a  stand  as  an  authority  from  its  first 
appearance,  and  every  one  interested  in  studvini;  the 
diseases  of  which  it  treats  is  desirous  of  knowinfr'\vh«t 
improvements  are  apparent  in  the  successive  oditiims. 
The  prin(i|,ial  additions  to  which  we  refer,  and  which 
will  be  the  distinp:ui<hinir  features  of  the  thinl  edition, 
are  chaplcru  on  diphtheria,  cerebro-spioal  meningitis, 
and  rotheln.  The  former  disease  is  considered  much 
more  in  detail  than  formerly,  and  a  great  amount  of 
very  practical  information  is  added,  and  altogether  it  is 
one  of  the  most  comprehensive  and  one  of  the  best  writ- 
ten chapters  of  the  subject  we  have  thus  far  read.  Ilis 
description  of  cerebrospinal  meningitis,  founded  also 
for  the  most  part  on  personal  experience,  is  admirably 
clear  and  exhaustive.— '/V/c  Me.d.  RecoixL  Feb.  19, 1S76. 

In  presentiuff  this  deservedly  popular  treati.so  for  the 
third  time  to  the  profession,  Dr.  Smith  has  given  it  a 
careful  preparation,  which  will  make  it  of  decided  su- 
periority to  either  of  the  former  editions.  The  position 
of  the  author,  as  physician  and  consultant  to  several 
lartre  children's  hospitals  in  New  York  City,  has  fur- 
nished him  with  constant  occasions  to  put  his  treatment 
to  the  test,  and  his  work  has  at  once  that  practical  and 
thoughtful  tone  which  is  a  marked  characteristic  ol  the 
best  productions  of  the  Aniericau  medical  press. — Ahd. 
and  fiurg.  Reporter,  Feb.  1876. 

The  former  editions  of  this  book  have  given  it  the 
highest  rank  among  works  of  its  class,  and  the  present 


edition  will  confirm  and  add  to  its  reputation  Ilnving 
bei'n  brought  up  to  the  presi-nt  mark  in  ihe  rapid  nU- 
vnnce  of  medical  science,  it  is  tlie  tiest  work  in  our 
language,  on  its  rant'e  of  topics,  for  the  .\ineric»ti  prac- 
titioner.— Pacific  Med.  und  Surg.  Jiiuru..  Kel)   1>76. 

Dr.  Smith's  Diseases  of  Phildren  is  cert.iinlv  the  most 
valuable  work  on  the  suljects  treated  tliai  ihe  practi- 
tioner can  provide  himself  wi'h.  It  is  fully  al'reast 
with  every  advance:  it  should  be  in  the  hands  of  prac- 
titioners generally,  while.  heiMUse  of  Ihe  conciseness 
and  clearness  of  style  of  Ihe  writini;  of  Ihe  author,  every 
profes.ior  of  diseases  of  children  if  he  has  not  nlready 
done  so,  shoidd  adopt  this  as  his  textbook  —  Va.  AUdical 
Monthly,  Feb.  1876. 

The  third  edition  of  this  really  valuable  work  is  now 
before  us.  wilh  a  hundred  pages  of  adriilional  maiter, 
an  altered  size  of  page,  new  illu-tralions.  and  new  type. 
Of  the  diseases  treated  of  for  the  first  finie.  we  notice 
rotheln  and  cerebro-spinal  fever,  whicli  laleh  |irev«iied 
in  epidemic  form  in  some  part^  id'  the  I'uunirv.  The 
article  upon  diphtheria,  containim:  the  latest  clev.Inp- 
ments  in  the  pathology  and  treatment  (.f  thai  dreail  dis- 
ease, which  so  lately  ruvaired  our  cioiniry.  is  piv  uliarly 
interesting  to  every  praciilioner.  We  irlaoh  welcome 
this  standard  work,  and  cljcerfiillv  recomipend  it  to  our 
readers  as  the  best  on  this  snhject  in  the  Kn-'lish  \nu- 
s.ua,'i,e.-^NashviUe  Journal  nf  Med.  anil  Snrgerii.  March, 
1876. 


fJONDIE  {D.  FRANCIS),  M.D. 

A  PRACTICAL  TREATISE  ON  THE  DISEASES  OF  CHILDREN. 

Sixth  edition,  revised  and  augmented.     In  one  large  octavo  volume  of  nearly  800  closely 
printed  pages,  cloth,  $5  25  ;  leather,  $6  25. 

The  present  edition,  which  is  the  sixth,  is  fully  up  I  teachers.  As  a  whole,  however,  the  work  is  the  bee* 
to  the  times  in  the  discussion  of  all  those  points  in  the  j  American  one  that  we  have,  and  in  its  special  adapt a- 
pathology  and  treatment  of  infantile  diseases  which  tion  to  American  practitioners  it  certainly  has  no 
have  been  bronghtforwardbytheOermauiindFrench  |  equal.  — JVew  York  Med.  Record.  March  2.  ISHfi. 


■  ^EST  (CHARLES),  M.D., 

'  '  Phyftician  to  the  Hospital  for  Sick  Ohild.ren,  4c. 

LECTURES  ON   THE   DISEASES   OF  INFANCY  AND  CHILD- 

HOOD.     Fifth  American  from  the  sixth  revised  and  enlarged  English  edition.     In  one  large 
and  handsome  octavo  volume  of  678  pages.    Cloth,  $4  50  ;  leather,  $5  50.    (Lotf/y  Tsfiied  ) 

The  continued  demand  for  this  work  on  both  sides  of  the  Atlantic,  and  its  trnnslntion  into  Ger^ 
man,  Frern^h,  Italian,  D.-inish,  Dutch,  and  Russian,  .show  that  it  fills  satisfactorily  a  want  exten- 
sively felt  by  the  profession.  There  is  probably  no  man  living  who  can  speak  with  the  authority 
derived  from  a  more  extended  experience  than  Dr.  West,  and  his  work  now  presents  the  results  of 
nearly  2000  recorded  cases,  and  600  post-mortem  examinations  selected  from  among  nearly  40,000 
oases  which  have  passed  under  his  care.  In  the  preparation  of  the  present  edition  he  has  omitted 
much  that  appeared  of  minor  importance,  in  order  to  find  room  for  the  introduction  of  ad<litionnl 
matter,  and  the  volume,  while  thoroughly  revised,  is  therefore  not  increased  materially  in  sixe. 

Of  all  the  English  writers  on  the  diseases  of  chil- 1  living  authorities  In  the  dlfllcnlt  department  of  medl- 
dren,  there  is  no  one  so  entirely  satisfactory  to  us  aa  I  cal  science  In  which  ho  Is  moBt  widely  known. — 
Dr.  West.     For  years  we  have  held  his  opinion  as  I  Boston  Med.  and  Surg.  Journal. 
Judicial,  and  have  regarded  him  as  one  of  the  highest  | 


or  THE  SAME  AUTHOR.    {Lately Issued.) 

ON  SOME  DISORDERS  OF  THE  NERVOUS  SYSTEM  IN  CHILD- 
HOOD; being  the  Lumleian  Lectures  delivered  at  the  Royal  College  of  Physicians  of  Lon- 
don, in  March,  1871.     In  one  volume,  small  12mo.,  cloth,  $1  00. 


22 


Hbnrt  C.  Lea's  Publications — {Diseases  of  Women). 


rpHOMAS  {T.GAILLARD),M.D., 

Professor  of  Obstetrics,  &c. ,  in  the  College  of  Physicians  and  Surgeons,  N. 


T.,  Ac. 

A  PRACTICAL  TREATISE  ON  THE  DISEASES  OF  WOMEN. 


Fourth 


edition,  enlarged  and  thoroughly  revised.     In  one  large  and  handsome  octavo  volume  of 

800  pages,  with  191  illustrations.     Cloth,  $5  00;  leather,  $6  00.     (Just  Issued.) 

The  author  has  taken  advantage  of  the  opportunity  afforded  by  the  call  for  another  edition  of 

this  work  to  render  it  worthy  a  continuance  of  the  very  remarkable  favor  with  which  it  ha.s  been 

received.     Every  portion  has  been  subjected  to  a  conscientious  revision,  and  no  labor  has  been 

spared  to  make  it  a  complete  treatise  on  the  most  advanced  condition  of  its  important  subject. 

A  work  wliich   lias  reached   a  fourth   udition,  and  i  pion  would  ronntrk  that,  as  a  teacher  o!  gyuiecology, 


that,  too.  in  the  .'ihort  space  of  five  years,  lias  achieved 
a  reputation  which  places  it  almost  beyond  the  reach 
of  criticism,  and  the  favorable  opinions  which  we  have 
already  expres.sed  of  the  former  editions  seem  to  re- 
quire that  we  should  do  little  more  than  announce 
this  new  issue.  We  cannot  refrain  from  saying  that, 
as  a  practical  worlc,  this  is  second  to  none  in  the  Eng- 
li.sh,  or.  indeed,  in  any  other  laiieaai;c.  The  arranjre- 
ment  of  the  contents,  the  adinirahly  clear  manner  in 
which  the  subject  of  the  differential  diagno.sis  of 
several  of  the  diseases  i-;  hamlled,  leave  nothing  to  he 
de.sired  by  the  practitioner  who  wants  a  thorou(;hly 
clinical  work,  one  to  which  he  can  re*'cr  in  difficult 
cases  of  doubtful  diasrnosis  «ith  the  certainty  of  cain- 
inir  light  and  instruction.  Dr.  Thomas  is  a  man  with  a 
very  clear  head  and  decided  views,  and  there  seems  to 
be  nothinj;  which  he  so  much  di'^likes  as  hazy  notions 
of  diagnosis  and  blind  routine  and  unreasonable  thera- 
peutics. The  student  who  will  thoroujilily  study  this 
book  and  test  its  principles  by  clinical  observation,  will 
certainly  not  be  guilty  of  these  faults.— London  Lancet, 
Feb.  13,  187.'). 

The  latest  edition  of  this  well-known  text-hook 
retains  the  essential  chHracters  which  rendered  the 
earliest  so  deservedly  popular  It  is  s;ill  pre-emi- 
neatly  a  practical  minual,  intended  to  convey  to 
studentsia  a  clear  and  forcible  manner  a  sufficiently 
complete  outl'ne  of  gynascology.  In  a  word,  we 
should  sai  that  anyone  who  intended  to  make  a 
special  study  of  gynjecology  could  hardly  do  better 
than  to  hpgin  with  a  minute  perusal  of  this  book,  and 
that  any  one  who  intended  to  keep  gynaecology  sub- 
ordinate to  geaeral  practice,  should  hardly  fail  to 
have  it  on  h*ud  for  future  reference. — N.  Y.  ifed. 
Joiirn.,  Jan.  1875. 


'  both  didacticand  clinical.  Prof  Thomasha-  certainly 
:  taken  the  lead  far  ahead  of  his  confrir-en,  and  as  an 
j  author  he  certainly  ha.s  r&et  with  nnn.-ual  and  mer- 
1  ited  success. — Am.  Journ.  of  Ohstetrici,  Nov,  1S74. 
I       This  volume  of  Prof.  Thomas  in  its  revised  form 
is  classical. without  being  pedantic,  full  in  i he  details 
of   anatomy    and    pathology,    without    ponderous 
translation  of  pages  of  (jeinnu  liteiatme,  describes 
distinctly  the  details  and  diflicaUies  of  each  opera- 
tion, without  wearying  and  useless  minutia;,  and  is 
in  ail  respects  a  work  wcrthy  of  confidence,  justify- 
ing the  high  resard  in  which  its  distinguished  au- 
thor is  held   by  the  profession. — Am.  Sup-plement, 
Obstet.  Journ.   Oct    1S74. 

Professor  Thomas  fairly  took  the  Profession  of  the 
Dnited  States  by  storm  whi^n  his  book  first  made  its 
appearance  early  in  IS6S,  Its  reception  was  simply 
enthusiastic,  notwithstanding  a  few  adverse  criti- 
cism-! from  our  transatlantic  brethren,  the  first  large 
edition  was  rapidly  exhausted,  and  in  six  mouths  a 
second  one  was  issued,  and  in  two  years  a  third  one 
was  announced  and  published,  and  we  are  now  pro- 
mised the  fourth.  The  popularity  of  this  work  was 
not  ephemeral,  and  its  success  was  unprecedented  in 
the  anna  Is  of  American  medical  literature.  Six  years 
is  a  long  period  in  medical  scientific  research,  but 
Tliomas's  work  on  "  Diseases  of  Women"  is  still  the 
leading  native  production  of  the  United  Slates.  The 
order,  the  matter,  the  absence  of  theoretical  dispula- 
tiveness,  the  fairness  of  statement,  and  the  elegance 
of  diction,  preserved  thronghoiit  the  entire  range  of 
the  book,  indicate  that  Professor  Thonian  did  not 
overestimate  his  powers  when  he  conceived  the  idea 
and  executed  the  work  of  producing  a  new  treatise 


upon  diseases  of  women. — Prop.  Palleji,  in  Louis- 
Reluctantly  we  are  obliged  to  close  this  nnsatis-  ;  ville  Med.  Journal,  Sept.  1S74. 
factory  notice  of  so  excellent  a  work,  and  in  concla-  ' 


B 


ARNES  {ROBERT),  M.  D.,  F.R.  C.P., 

Ohntetric  Physician  to  St.  Thomas's  Hospital,  A-e. 

A  CLINICAL  EXPOSITION  OF  THE  MEDICAL  AND  SURGI- 
CAL diseases  OF  WOMEN.  Second  American,  from  the  Second  Enlarged  and  Revised 
English  Edition.    In  one  handsome  octavo  volume,  with  many  illustrations.    {In  Press.) 

Ct WAYNE  {JOSEPH  GRIFFITHS),  M.D., 

*-'  Phi/Dieian-Accoiicheur  to  the  British  General  Hospital,  Ac. 

OBSTETRIC  APHORISMS  FOR  THE  USE  OF  STUDENTS  COM- 
MENCING MIDWIFERY  PRACTICE.     Second  American,  from  the  Fifth  and  Revised 
London  Edition,  with  Additions  by  E.  R.  Hutchins,  M,  D.     With  Illustrations.     In  one 
neat  12ino.  volume.     Cloth,  $1  25.     (Lately  Issued.) 
***_  See  p.  4  of  this  Catalogue  for  the  terms  on  which  this  work  is  offered  as  a  premium  to 
subscribers  to  the  "  American  Journal  of  the  Mkdical  Sciences." 


fTODOE  {HUGH  L.),  M.D., 

./.J.  Emeritus  Professor  of  Obstetrics,  Ac,  in  the  University  of  Pennsylvania. 

ON  DISEASES  PECULIAR  TO  WOMEN;  including  Displacements 

of  the  uterus.     With  original  illustrations.     Second  edition,  revised  and  enlarged.     In 
one  beautifully  printed  octavo  volume  of  531  pages,  cloth,  $4  50. 

From  Prof.  W.  H.  Btpord,  of  the  R^lsh  Medical  Professor  Hodge's   work  is   truly  an  original  one 

College,  Chicago.  from  beginning  to  end,  consequently  no  one  can  pe- 

The  book  bears  the  impress  of  a  master  hand,  and  '^^^  ''*  pages  without  learning  something  new.  Asa 

jaust,  as  its  predecessor,  prove  acceptable  to  the'  pro-  contribution  to  the  study  of  women's  di-eases,  it  is  of 

fession.     In  diseases  of  women  Dr.  Hodge  has  estab-  Si'eat  value,  and  is  abundantly  able  to  stand  on  its 

lished  a  school  of  treatment  that  has  become  world-  0'^°  merits.— A^.  T.  Medical  Record,  Sept.  15,  1868. 
wide  in  fame. 


oHDRCHILL   ON  THE   PUERPERAL   FEVER  AND  I  MEIGS   ON   THE   NATURE.   SIONS,    AND   TREAT. 
OTHER  DISEASES  PECULIAR  TO  WOMEN.    1vol.         MENT  OF  CHILDBED  FEVER.     1    vol.  8vo     pp 
,  pp   450,  cloth.    $2  50.  |      ^65.  cloth.    $2  00. 


Svo. 


Henry  C.  Lea's  Fublioations — (Bueases  of  Wonieti). 


23 


QHADWICK  [JAMES  R.),  A.M.,  M.D. 

A  MANUAL  OF  THE  DISEASES   PECULTAK  TO  WOMEN.      Li  one 

neat  volume,  royal  12mo.,  with  illustrations.  {Preparii/g.) 
Amerio.T  has  contributed  so  larj^ely  to  the  advances  which  have  made  the  treatment  of  Dis- 
eases of  Women  a  distinctive  department  of  medical  science,  that  (he  student  will  naturally 
turn  to  Aineriean  Books  for  the  latest  and  most  trustworthy  instruction  on  the  subject  in  its 
most  modern  aspect.  Yet  there  has  thus  far  been  no  attempt  in  this  country  to  produce  ii  h.'indy 
manual,  presenting  in  a  condensed  and  con  ven lent  form  the  information  requisite  for  the  learner 
or  for  the  general  practitioner.  This  want  it  has  been  the  effort  of  Dr.  Chadwick  to  supjily,  and 
the  special  attention  whicli  he  has  devoted  to  the  subject  is  a  guarantee  of  the  value  of  his  labors. 
A  distinguishing  feature  of  the  work  will  be  a  number  of  diagrammatic  illustrations,  facilitating 
greatly  the  comprehension  of  the  text. 


TU'INCKEL  {F.), 

'  '  Prnfe.isor  and  Director  of  the  GynacoJogicdl  Clinic  in  the  University  of  Rostock. 

A  COMPLETE  TREATISE  ON  THE  PATHOLOGY  AND  TREAT- 
MENT OF  CHILDBED,  for  Students  and  Practitioners.  Translated,  with  the  consent  of 
the  author,  from  the  Second  German  Edition,  by  James  Read  Chadwiok,  M  D.  In  on« 
octavo  volume.     Cloth,  $4  00.      {Lately  Issued  ) 

Thi.s  work  w.as  writlen.  a.i  the  author  tell."!  ns  in  his 
preface,  to  supply  a  want  arisinji  J'rom  the  very  brief 
I'onsitlcration  siven  to  puerpi-ral  (li.''i'a.--es  by  wriicrs  on 
Obstetrics,  in  which  respect  it  seems  the  profession  in 
his  country  is  not  difTerent  from  our",  and  to  fill  ii  blank 
left  between  the  treatises  upon  the  subject  already  in 
the  field,  and  the  present  standpoint  of  science  The 
work  has  reached  a  second  editinn.  and  liear.';  efiilenot- 
throu'jhout  of  careful  study  and  practical  experience 
.Cs  its  title  implies,  it  is  a  manual  rather  than  a  treatise. 
— Am-erican  Journal  of  Med.  Scitucei:  April,  b-^Tl. 


We  feel  quite  sore  that  the  profession  of  this  country 
will  give  this  interesting  and  learned  work  a  cordial 
welcome  —  Cincinnati  Med.  JVeivs.  .Tune,  ISTti. 

In  Germany  this  treatise  is  rejjrarded  as  a  standard 
av\thority  in  this  branch  of  medicine,  and  as  it  con- 
tains the  recent  .advances  in  the  pathology  and  treat- 
ment of  diseases  that  pertain  to  the  puerperal  condition, 
will  be  <rladiy  received  by  a  large  portion  of  the  profes- 
sion in  this  country. — Cincinnati  Lancet  and  Observer. 
June,  1S76. 


JYEST  (CHARLES),  31. D. 

LECTURES  ON  THE  DISEASES  OF  WOMEN. 

from  the  Third  London  edition. 
$3  75  ;  leather,  $4  75. 


Third  American, 

In  one  neat  octavo  volume  of  about  550  pages,  cloth, 


DaWEES'S  TREATISE  ON  THE  DISEASES  OF  FE- 
MALES. With  illustrations.  Eleventh  Edition. 
with  the  Anther's  last  improvements  and  correc 
tions.  In  one  octavo  volume  of  .'i.^fi  nases.  witv 
plates,  cloth.    $3  no 


ASHWELL'S  PRACTICAL  TREATISE  ON  THE  DIS- 
EASES PECULIAR  TO  WOMEN.  Third  American, 
from  the  Third  and  revised  London  edition.  1  vol. 
8vo.,  pp.  528,  cloth.    $3  60. 


JfANNER  (THOMAS  H),  M.D. 
ON  THE  SIGNS  AND  DISEASES  OF  PREGNANCY.     First  Americm 

from  the  Second  and  Enlarged  English  Edition.     With  four  colored  plates  andillustratior  s 
on  wood.     In  one  handsome  octavo  volume  of  about  600  pages,  cloth,  $4  25. 


rpHE  OBSTETRICAL  JO  URNAL.     [Free  of  postage  for  1878.) 

THE    OP>STETRICAL    JOURNAL   of  Great  Britain  and  Ireland; 

Including  Midwifery,  and  the  Diseases  op  Women  and  Infants.     With  an  American 
Supplement,   edited  by  J.   V.  Inouam,   M.D.       A  monthly  of   about  flfi    octavo  pages, 
v^ry  handsomely  printed.     Subscription,  Five  Dollars  per  annum.     Single  Numbers,  50 
cents  each. 
Commencing  with  April,  187.3,  the  Obstetrical  Journal  consists  of  Original  Papers  by  Brit- 
ish and  Foreign  Contributors  ;   Transactions  of  the  Obstetrical  Societies  in  England  and  abroad  ; 
Reports  of  Ilospitil  Practice;  Reviews  and  Bibliographical  Notices;   Articles  and  Notes,  Edito- 
rial,  Historical,  Forensic,  and  Miscellaneous;  Selections  from  Journals;   Correspondence,  Ac- 
Collecting  together  the  vast  amount  of  material  daily  accumulating  in  this  important  and  ra- 
pidly improving  department  of  medical  science,  the  value  of  the   information  which  it  pre- 
sents to  the  subscriber  may  be  estimated  from  the  character  of  the  gentlemen  who  have  already 
promised  their  support,  including  such  names  as  those  of  Drs.  Atthili,,  Avklinc,  Hoiikrt  B.aiines, 
J.   Henrt  Bennet,  Nathan  Bozeman,  Thoma.'!  Chambers.  Fleetwood  CnnRriiit.i..  Cn.Ani.KS 
Clay,  Jonv  Clay,  Matthews  Duncan,    Autfiur  Farre,  Robert  OREENnALon.  Gr.\ily  Hew- 
itt, Braxton  Hicks,  Alfred  Meadows,  W.    Leishman,  Alex.   Simpson,   Hkywood  Smith. 
Tyler  Smith,  Edward  J.  Tilt,  Lawson  Tait,  Spencer  Wells,. tc.  Ac;  in  short,  the  repre- 
sentative men  of  British  Obstetrics  and  Gyntneology. 

In  order  to  render  the  Obstetrical  Journal  fully  adequate  to  the  wants  of  the  American 

profession,  each  number  contains  a  Supplement  devoted  to  the  advances  made  in  Obstetrics  and 

Gynaecology  on  this  side  of  the  Atlantic.     This  portion  of  the  Journal  is  under  the  editorial 

.charge  of  Dr.    J.   V.   Ingham,  to  whom    editorial    communications,  exchanges,   books    for    re- 

iview,  Ac,  may  be  addressed,  to  the  care  of  the  publisher. 

*^*  Complete  sets  from  the  beginning  can  no  longer  be  furnished,  but  subscriptions  can  coir- 
imence  with  January,  187S,  or  Vol.  VI.,  No    1,  April,  1878. 


24 


Hbney  0.  Lea's  Publtoations — (Midwifery). 


P 


LAYFAIR  (  W.  S.\,  M.D.,  F.R.C.P., 

Professor  of  Obstetric  Medicine  in  King's  College,  etc.  etc. 


A  TREATISE  ON  THE  SCIENCE  AND  PRACTICE  OF  MIDWIFERY. 

Second  American,  from  the  Second  and  Revised  English  Edition.     Edited,  with  Addi- 
tions, by  RoBBirr  P.  Harris,  M.D.    In  one  handsome  octavo  volume  with  numerous  illus- 
trations.    (Prepari7i,g-.)    ; 
The  very  remarkable  success  which  hns  in  so  short  a  tiaie  exhausted  the  first  editions  of  this 
work,  in  both  England  and  America,  shows  that  the  author  has  successfully  .supplied  an  acknowl- 
edged want  of  a  work  which,  within  a  moderate  compass,  should  serve  as  a  guide  to  the  most 
recent  condition  of  obstetric  art  and  science. 

A  few  notices  of  the  previous  edition  are  appended. 

The  author's  reputation  was  fulficient  to  warrant  i  containing  the  very  latest  information  resjarding  the 
gi'eat  expectation.i,  when  liis  forthconiiuf;  work  was  an-  subject  of  ob-tetrics,  full  of  hints  of  the  greatest  prac- 
nounced.  and  its  appearance  has  caused  no  disappoint-  tical  value.  'I'his  work  will  tind.  we  predict,  a  large  and 
nient  It  deals  in  a  masterly  way  wilh  many  dispuled  ready  sale  The  book  is  profusely  illustrated  with  vaJu- 
points.  and  t;lve8  conclusions  which  it  would  be  difficult  i  able  wood-cuts,  and  is  printed  in  beautiful  type. — Cin- 


to  gainsay.     The  work  is  the  most  valuable  acquisition  j 
to  tlie  subject  on  which  it  treats  which  has  been  given  ' 
the  profession  in  a  lonp;  time,  and  in  saying  this  we  do 
not  forgpt  the  many  admirable  treatises  which  have  re 
ceutly  appeared.     Is'o  practitioner  can  alford  to  be  with 
out  it  —Peninsular  Journ.  of  Med.,  Sept.  1S75. 

The  high  reputation  already  won  by  Dr.  I'layfair  in 
this  special  departnientof  medicine  is  a  sufficient  guar- 
antee fur  the  meritorious  characterof  this  work.  Kverv 


cinnoti  Lnnii'l  and  Observer.  Nov.  1876 

This  is  pre-oniineutly  a  work  adapted  to  the  wants  of 
students,  and  will  do  more  towa  d  accomplishing  the 
prolession  a'  large  in  that  particular  branch  of  medicine 
than  any  other  work  in  the  field  of  ob^tetric  literature. 
In  praise  of  this  work  too  much  cannot  be  said — in  ad- 
verse criticism  very  little  We  advi.se  every  student 
anii  ever\  graduate  to  obtain  it.  and  hope,  ere  long,  to 
■see  it  adopted  as  the  principal  text  booK  of  obstetric 
medicine  in  every  college  in  the  United  States. — Nash- 


page  is  replete  with  interesting  and  instructive  matter,    ville  Mfd.  and  iiurg.  Jouni,.,  Oct.  1876. 


H 


ODGE  [HUGH  L.).  31.  D., 

EmeritUK  Professor  of  Midwifery,  *«?..  in  the  University  of  Pennsylvania,  &c. 

THE   PRINCIPLES  AND   PRACTICE   OF   OBSTETRICS.     Illus- 

trated  with  large  lithographic  plates  containing  one  hundred  and  fifty-nine  figures  from 
original  photographs,  and  with  numerous  wood-cuts.  In  one  large  and  beautifully  printed 
quarto  volume  of  550  double-columned  pages,  strongly  bound  in  cloth,  $14. 

The  work  of  Dr.  Hodge  is  something  more  than  a[  obstetricians.  Of  the  American  works  on  the  subject 
simple  presentation  of  his  particular  views  in  the  de-Utis  decidedly  thebeHt. — Edinb.  Med.  Jour.,  Dec.  '64. 
partment  of  Obstetrics;  it  is  something  more  than  anl  We  have  read  Dr.  Hodge's  book  with  great  plea- 
ordinary  treatise  on  midwifery  ;  it  is.  in  fact,  a  cyclo-' sure,  and  have  much  satisfaction  in  expressing  our 
pedia  of  midwifery.  He  has  aimed  to  embody  in  atcommendaiion  of  it  asa  whole.  It  is  certainly  highly 
single  volume  the  whole  science  and  art  of  Obstetrics  (instructive,  and  in  the  main,  we  believe,  correct.  The 
An  elaborate  text  is  combined  with  accurate  and  va-!greal  attention  which  the  author  has  devoted  to  the 


ried  pictorial  illustrations,  so  that  no  fact  or  principle 
Is  left  unstated  or  unexplained. — Am.  Med.  Times, 
Sept.  .3.  1S64. 

It  IS  very  large,  profusely  and  elegantly  illustrated, 
and  is  fitted  to  take  its  place  near  the  works  of  great 


mechanism  of  parturition,  taken  along  with  the  con- 
clusions at  which  he  has  arrived,  point,  we  think, 
conclusively  to  the  fact  that,  in  Britain  at  least,  the 
doctrines  of  Naegele  have  been  too  blindly  received. 
— Olasyow  Med.  Journal,  Oct.  1864. 

***  Specimens  of  the  plates  and  letter-press  will  be  forwarded  to  any  address,  free  by  mail, 
on  receipt  of  six  cents  in  postage  stamps. 


j^AMSBOTHAM  [FRANCIS  H.),  M.D.  i 

THE  PRINCIPLES   AND    PRACTICE   OF   OBSTETRIC  MEDI- 

CINE  AND  SURGERY,  in  reference  to  the  Process  of  Parturition.  A  new  and  enlarged 
edition,  thoroughly  revised  by  the  author.  With  additions  by  W.  V.  KEATiNG,tM.  D., 
Professor  of  Obstetrics,  .fee.,  in  the  Jefferson  Medical  College,  Philadelphia.  In  one  large 
and  handsome  imperial  octavo  volume  of  650  pages,  strongly  bound  in  leather,  with  raised 
bands  ;  with  sixty-four  beautiful  plates,  and  numerous  wood-cuts  in  the  text,  containing  in 
all  nearly  200  large  and  beautiful  figures.     $7  00. 


fjHURCHJLL  [FLEETWOOD),  M.D.,  M.R.I. A. 

ON  THE  THEORY  AND  PRACTICE  OF  MIDWIFERY.    A  new 

American  from  the  fourth  revised  and  enlarged  London  edition.  With  notes  and  additions 
by  D.  Francis  Condie,  M.  D.,  author  of  a  "Practical  Treatise  on  the  Diseases  of  Chil- 
dren,"  <fcc.  With  one  hundred  and  ninety-four  illustrations.  In  one  very  handsome  octavo 
volume  of  nearly  700  large  pages.     Cloth,  $4  00;  leather,  $5  00. 


MONTGOMERY'S    EXPOSITION    OF    THE    SIGNS  i  RIGBT'S  SYSTEM  OP  MIDWIFERY.    With  Note* 
AND  SYMPTOMS   OF    PREGNANCY.     With  two  j      and   Additional   lUnstrations.     Second   American' 
exquisite  colored  plates,  and  numerous  wood-cuts.  I      fldltion.     One   volume   octavo,  cloth    422  page* 
In  1vol. 8vo.,ofnearly600pp., cloth.   |.3  75.  I      $2  60. 


Henry  C.  Lea's  FvBLiOATwm— {Midwifery,  Surgery).  25 

J^EISHMAN  (  WILLIAM),  M.D.,  ~ 

Mtffius  Prnfessor  of  Midwifery  in  thf.  UniverHty  of  Glasgow  &c 

A  SY8TEM  OF  MIDWIFERY,  INCLUDlxXG  THE  DISEASFS  OF 

PREGNANCY  AND  THE  PUEUPErAl  STATE.  Second  Amticanfrrthelo^nd 
ami  Revised  Enghsh  Edition  ,viih  additions  by  John  S.  Paukv,  M.D.,  Obstetrician  to  the 
PbUadelplna  Hospital,  Ac.  In  one  large  and  very  handsome  octavo  ;olume  of  over  700 
pages,  with  about  two  hundred  illustrations  :  cloth,  $5  ;  leather,  $G.  {Jn,tuTved.\ 
That  thii-  book  is  recommended  as  a  text-l)oi)k  by 

many  of  the    Uadlng   scholurs  of  medicine   in    this 

coautry,  issuflicieat  evideuce  of  the  faroi- in  whiih 

it  is  held.     Iq  a  word   we  kuow  of  no  bettpi- hook  ia 

oar  language,  l)0(h  for  the  studeut  and  pracliticner. 

The  value  of  the  book  is  euhauced    by  this   secoud 


edition,  which  contains  many  notes  by  our  lile  Dr. 
Parry.— C/ucrtfifo  Mtd.  Journ.  and  Exaiuiner  March 

1S77. 

But  the  most  valuable  additions  to  the  volume  are 
those  made  by  the  American  editor.  One  of  the  hesi  tc.'^ts 
of  a  man's  ability  is  fur  him  to  take  a  standiird  work  in 
our  prot'e.s,sion.  like  this  ofDr.LeishniHn,  and  materially 
improve  it.  Many  a  one,  with  more  ambilimi  ih;iu  wi..!- 
dom,  has  attempted  it  with  other  books  and  failed.  Hut 
Dr.  Farry  has  succeeded  most  admirably.  We  know  no 
obstetrical  work  that  has  anything  belter  on  the  use  of 
the  forceps  than  that  which  Dr.  Parry  has  civen  in  this, 
and  no  work  that  has  the  rational  and  intelligent  views 
upon  lactation  with  which  he  has  enriched  this,  liaving 
used  •' Lcishman"'  for  two  years  as  a  textbook  for  stu- 
dents, we  can  cordial  I  y  commend  it,  and  are  quite  sati.sfied 
to  continue  .such  use  now. — Am.  Pradiliontr,  JIar.  1876. 

This  new  edition  decidedly  confirms  the  opinion  which 
we  expi-essed  of  the  first  edition  of  the  work,  in  the  .May. 
1ST4,  number  of  this  Journal,  that  this  is  -'the  best 
modern  work  on  the  sul'ject  in  the  Knglish  language." 


The  excellent  practical  notes  contributed  bv  Dr  Parry 
refer  principally  to  the  use  of  the  forceps,  lactation,  and 
the  puerperal  diseases,  and  are  intended  to  incrc-i.se  the 
usefulnessof  the  work  in  this  country.  An  entirely  new 
chapter  on  diphtheria  of  puerperal"  wounds  Unn  hcen 
addeil  (Dr.  I',  has  had  unusual  experience  in  tlii-  form 
ot  p\ierperal  fever),  nod  also  a  number  of  illustrations 
of  the  principal  obstetrical  instruments  in  n,«e  in  Ame- 
rica. We  have  no  hesitation  in  saying  tliatthe  work,  in 
its  present  shape,  is  a  great  improvement  on  its  prede- 
cessor, and  in  recommending  it  as  tlie  one  oljstetrical 
text- hook  which  we  should  advise  every  Knglish  ppeak- 
ing  practitioner  and  student  to  buy.— tinier jcan  Jour- 
nal of  Obstetrics,  Feb.  1870. 

Perhaps  the  most  u.seful  one  the  student  can  procure. 
Some  important  additions  have  been  made  by  llie  editor, 
in  order  to  adapt  the  work  to  the  profession  in  this  coun- 
try, and  some  new  illustrations  have  been  introduced, 
to  represent  the  obstetrical  instruments  generally  em- 
ployed in  American  practice.  In  its  present  form',  it  is 
an  exceedingly  valuable  book  for  botli  the  student  and 
practitioner. — N'ew  Turk  Med.  Journal,  Jan.  1876. 

In  about  two  years  after  the  issue  of  this  excellent 
treatise  a  second  edition  has  been  called  for.  We  regard 
the  treatise  as  thoroughly  sound  and  practical,  and  one 
which  may  wilh  conlidence  be  consulted  in  any  emer- 
gency.—yVit!  London  Lanctl,  Dec.  11,  1&76. 


pARRY  {JOHN  S.),  31. D., 

Ob. 'iU.tr  ici  an  to  the  Philadelphia  Ho.ipital,  Vice-Pre>it.  of  the  O'istet.  Siciefy  of  Philadelphia 

EXTRA-UTERINE    PREGNANCY:    ITS    CLINICAL    HISTORY, 

DIAGNOSIS,    PROGNOSIS,  AND   TREATMENT.     In  one   handsome  octavo  volume. 
Cloth,  $2  &0.     {Lately  Issued.) 


It  is  with  ireniiine  satisfaction,  therefore,  that  we  read 
the  work  before  us.  which  is  far  in  advance  of  any  mo- 
nograph upon  the  subject  in  the  English  language,  and 
exceeding  very  much,  in  the  number  of  cases  upon 
which  it  is  based,  we  believe,  any  work  of  the  kind  ever 
published.  The  author  has  given  great  care  and  study 
to  the  work,  and  has  handled  bis  statistics  with  .iudg- 
ment ;  so  ihat,  whatever  was  to  be  gained  from  them, 
he  has  gained  and  added  to  our  knowledge  on  llie  sub- 
ject. We  owe  the  author  much  for  giving  us  a  clear, 
readable  book  upon  this  topic.  He  has,  so  far  a*  it  is 
at  present  possible,  removed  the  obscurity  attending 
certain  points  of  the  subject.    He  has  brought  order 


oui  of  something  very  like  chaos. — Philadelphia  M-'d 
Times,  Keb.  19,  1870. 

In  this  work  Dr.  Parry  has  added  a  most  valuahle 
contribution  to  ol>stetric  literature,  and  one  which  meets 
a  want  long  felt  by  those  of  the  profession  who  have 
ever  been  called  upon  to  deal  with  this  cla-s  of  ca.ses. — 
lioston  Me.d.  and  Sitry.  Journ...  March  9,  187b. 

This  work,  being  as  near  as  possible  a  collection  of  the 
experiences  of  many  per.<ons,  will  afford  a  most  useful 
guide,  both  in  diagnosis  and  treatment,  for  this  most 
interesting  and  fatal  malady.  We  think  it  should  be  in 
the  hands  of  all  physicians  practising  midwifery. — Cin- 
cinnati Clinic,  Kel).  5,  lb7C. 


ASHEURST  {JOHN,  Jr.),  M.D., 

Prof,  of  Clinical  Suryr;/.  Univ.  of  Pa..  Surgeon  to  the  Episcopal  Hospital,  Philadelphia. 

THE   PRINCIPLES   AND   PRACTICE  OF   SURGERY.    In  one 

very  large  and  handsome  octavo  volume  of  about  1000  pages,  with  nearly  550  illustratione, 

cloth,  $6  50;  leather,  raised  bands,  $7  50. 
Its  author  has  evidently  tested  the  writings  and  [  )pinlonB  of  others.  He  Isconsorvativp,  bnl  not  hide- 
experiences  of  the  past  and  present  in  the  crucible  i  bound  by  anth.irity.  His  Ktyle  is  clear,  eleg«Dl.  and 
of  a  careful,  analytic,  and  honorable  wind,  and  faith-  !  scholarly.  The  wcrk  is  an  admirable  text-book,  and 
fully  endeavored  to  bring  his  work  npto  the  level  of  I  a  useful  book  of  reference.  It  is  a  credit  to  American 
the  highest  standard  of  practical  surgery.  He  is  j  piofessional  literature, and  oneof  the  first  ripe  fruits 
frank  and  definite,  and  gives  us  opinions,  and  gene-  1  )f  the  soil  ferliliied  by  the  blood  of  our  lale  uuliii(.)iy 
rally  sound  ones,  instead  of  a  mere  r«««m^  of  the  I  va,t.—lf.  T.  Med.  Record,  Feb.  1,  1872. 


SKEY'S  OPERATIVE  SURGERY.  In  1  vol.  8vo. 
cl.,  of6/)0  pages  :  withabontlOOwood-cnts  *3  2.') 

COOPER'S  LECTURES  ON  THE  PRINCIPLES  AND 
Practice  OF  SiT.tnERT.  Inlvol-'^vo  cloth,7.'iop.  $2. 

GIBSON'S  INSTITUTES  AND  PRACTICE  OF  SPR- 
OERT.  Eighth  edition,  improved  and  altered.  With 
thirty-f<oir  plates.  In  two  handsome  octavo  vol- 
nmes.  about  lonopp.. leather,  raised  band'    i>fi  ^<^ 

THE  PRINCIPLES  AND  PRACTICE  OF  SURGERY. 
By  William  Piruik,  F.R  S.K.,  Professor  of  Surgery 
In  the  University  of  Aberdeen.  Edited  by  John 
Neill,  M.D.,  Professor  of  Surgery  in  the  Penna. 


Medical  College,  Surgco a  tothePennRylvanlallos 
pital,  iSic.  Ia  one  very  handsome  octavo  vohiuie  of 
7S0  pages,  with  .310  iUustrallons,  clotli,  $.1  7.'). 
\tn,bi;K'.>  fltlNCIl'LKSOK.^riUJKKV.  Fourth  fcmo- 
riciin,  from  the  Third  Kdiiiburgh  Kilitlon.  In  one 
large  Rvo.  vol.  of  7D0  pages,  wilh  U40  illustrations  : 
cloth.  i».T  75, 

MILLKirS  PRACTICE  OFSURCKRY.  Fourth  Ame- 
rican, from  the  last  Konliurgh  Kdition.  Ituvlsed  by 
the  American  editor.  Ii  inelarge  Svo.vol.of  ne»rly 
700  pages,  with  364  illustrations:  cloth,  $3  76. 


26 


Henry  C.  Lba's  Publioations — (Surgery). 


G 


IROSS  {SAMUEL  D.),  M.D., 

Professor  of  Surgery  in  the  Jefferson  Medical  College  of  Philadelphia. 


A  SYSTEM  OF  SURGERY:   Pathological,  Diagnostic,  Therapeutic, 

and  Operative.     Illustrated  by  upwards  of  Fourteen  Hundred  Engravings.     Fifth  edition, 
carefully  revised,  and  improved.    In  two  large  and  beautifully  printed  imperial  octavo  vol- 
umes of  about  2300  pages,  strongly  bound  in  leather,  with  raised  bands,  $16.    (Just  Issued.) 
The  continued  favor,  shown  by  the  exhaustion  of  successive  large  editions  of  this  great  work, 
proves  that  it  has  successfully  supplied  a  want  felt  by  American  practitioners  and  students.    In  the 
present  revision  no  pains  have  been  spared  by  the  author  to  bring  it  in  every  respect  fully  up  to 
the  day.     To  effect  this  a  large  part  of  the  work  has  been  rewritten,  and  the  whole  enlarged  by 
nearly  one-fourth,  notwithstanding  which  the   price  has  been  kept  at  its  former  very  moderate 
rate.     By  the  use  of  a  close,  though  very  legible  type,  an  unusually  large  amount  ol  matter  is 
condensed  in  its  pages,  the  two  volumes  containing  as  much  as  four  or  five  ordinary  octavos. 
This  combined  with  the  most  careful  mechanical  execution,  and  its  very  durable  binding,  renders 
it  one  of  the  cheapest  works  accessible  to  the  profession.     Every  subject  properly  belonging  to  the 
domain  of  surgery  is  treated  in  detail,  bo  that  the  student  who  possesses  this  work  may  be  said  to 
have  in  it  a  surgical  library. 

We  bitve  now  Inoui^lit  iiur  Insk  to  a  conclusion,  and 
have  seldc'Ui  read  a  work  wiih  tlie  practical  value  ol 
which  we  liave  been  u)oreimpres.«ed.  Kveiy  chapter  is 
so  ciincisely  put  together,  tluit  the  busy  practitioner, 
wlieii  ill  difiicuity.  can  at  once  find  the  inforniation  he 
requires.  His  work,  ou  the  coutiary.i.s  cosmopolitan, 
the  sunicry  ol  the  world  beini;  fully  represented  in  it. 
The  wi'i-k.  in  fact,  is  so  historically  unprejudiced. and  so 
eiiiiiieutly  practical,  that  it  is  almost  a  false  compliment 
to  say  that  we  believe  it  to  be  destined  to  occupy  a  fore- 
most" place  as  a  work  ofreference,  while  a  system  of  sur- 
gery likethe  present  system  of  surgery  is  the  practiceof 
surgeons.  The  prinlinitand  binding  of  the  work  is  un- 
exceptionable; indeed,  it  contrasts,  in  the  latter  re- 
spect remarkably  with  Kncrlish  medical  and  surgical 
cloth- bound  publications,  whicharenenerally  so  wretrii- 
edlv  stitched  as  to  require  rc-biudinj:  before  they  are 
any  time  in  use.— Dub.  Journ. (if  '^ted.Sci.,Ha.Tcii,  1&74. 
Dr.  Gros.s's  Sursery,  a  great  work,  has  become  .still 
ijreatev,  both  in  sfze  and  merit,  in  its  most  recent  form. 
The  difference  in  act  ualnumberof  pages  is  not  more  than 
loO.  but.  the  size  of  the  page  having  been  increased  to 
wliatwe  believe  is  technically  termed  -elcphanl."  there 
has  been  rooai  for  considerable  additions,  which,  toge- 
ther with  the  alterations,  are  improvements.— iojirf. 
Lancet,  Nov.  16, 1872. 

It  combines,  as  perfectly  ns  possible,  the  qualities  of 
a  text-book  and  work  of  reference.  We  think  this  last 
eaition  of  Gross's  '-Surgery,"  will  confirm  his  title  of 


"  Primus  inter  Pares."  It  is  learned,  scholar-like,  me- 
thodical, precise,  and  exhaustive.  We  scarcely  think 
any  living  man  could  write  .so  complete  and  faultless  a 
treatise,  or  comprehend  more  solid,  instructive  matter, 
in  the  given  number  of  pages.  The  labor  must  have 
been  immense,  and  tlie  work  gives  evidence  of  great 
powers  of  mind,  and  the  highest  order  of  intellectual 
discipline  and  me'hodical  disposition,  and  arrangement 
of  acquired  knowledge  and  personal  experience. — JV.  Y. 
Med  .Toitm..  Feb.  1873 

As  a  whole,  we  regard  the  work  as  the  representative 
"System  of  Surgery"  in  the  Knglish  language. — St. 
Louis  Medical  and  Sur(/.  Journ.,  Oct.  1872. 

The  two  magnificent  volumes  before  us  afford  a  very 
complete  view  of  the  surgical  knowledge  of  the  day. 
Some  years  ago  we  had  the  pleasure  of  pre.-^enting  the 
first  edition  of  Gross's  Surgery  to  the  profe.-sion  as  a 
work  of  unrivalled  excellence:  and  now  we  have  the 
result  of  years  of  experience,  labor,  and  study,  all  con- 
densed upon  the  great  work  before  us  And  tosludents 
or  practitioners  ilesirous  of  enric-hing  their  library  with 
a  treasure  of  reference,  we  can  simply  commend  the 
purchase  of  these  two  volumes  of  immense  research.- 
Oincinnati  Lancet  and  Observer,  Sept.  1(372. 

A  complete  system  of  surgery — not  a  mere  text-book 
of  operations,  but  a  scientific  account  of  surgical  theory 
and  pra<ticeitiall  its  departments. — Brit.and  For.  Med.- 
Chir.  Rev.,  Jau.  1873. 


jDr  THE  S.iME  AVTUOR. 

A    PRACTICAL   TREATISE    ON  THE    DISEASES,   INJURIES, 

and  Malformations  of  the  Urinary  Bladder,  the  Prostate  Gland,  and  the  Urethra.  Third 
Edition,  thoroughly  Revised  and  Condensed,  by  Samuel  W.  Gkoss,  M.D.,  Surgeon  to 
the  Philadelphia  Uospiial.  In  one  handsome  octavo  volume  of  574  pages,  with  170  illus- 
trations:  cloth,  $4  50.     {Just  Issued.) 


The  book  is  fully  up  to  the  times,  and  we  know  of  no 
monograph  on  the  subject  of  urinary  diseases  that  is 
fuller  and  more  complete  than  the  one  under  notice. — 
Oincin.  Lancet  and  Observer,  Deo.  1676. 

It  is  a  valuable  and  exhaustive  treatise  on  the  surgery 
of  the  urinary  organs,  brought  fully  up  to  the  existing 
state  of  our  knowledge.  A  perusal  of  its  .574  pages  will 
amply  repay  the  iuvestigalor.— Pac(/ic  Med.  ai.d  tfary. 
Journ,  Nov.  1876. 

Nothing  need  be  said  to  commend  this  standard  work 
to  the  profession.  It  has  long  been  con.sidered  one  of 
the  most  valuable  from  the  pen  of  the  distinguished 
author.  The  editor  has  done  liis  work  ably  and  faith- 
fully, and  several  of  the  chapters,  by  no  means  the  least 
useful  ones,  are  from  his  pen;  as  a  monograph  repre- 
senting all  the  surgery  of  the  parts  of  which  it  treats, 
it  l\as  no  superiorin  our  tongue.— J/eiZ.  and  Surg.  Re- 
porter,  Oct.  21,  1876. 

For  reference  and  general  information,  the  physician 


or  surgeon  can  find  no  work  that  meets  their  necessities 
more  thoroughly  than  this,  a  revised  edition  of  an  ex- 
cellent treatise,  and  no  medical  library  should  be  with- 
out it.  Keplete  with  handsome  illustrati'ns  and  good 
ideas,  it  has  the  unusual  advantage  of  being  easily 
comprehended,  by  the  reasonable  and  practical  manner 
in  which  the  various  subjects  are  sy»teuuitized  and 
arranfc.ed  We  heartily  recommend  it  to  the  profession 
as  a  valuable  addition  to  the  important  literature  of  dis- 
eases of  the  urinary  organs. — Atlanta  Med.  Journ.,  Oct. 
1876. 

It  is  with  pleasure  we  now  again  take  up  this  old  work 
in  a  decidedly  new  dress.  Indeed,  it  must  be  regarded 
as  a  new  book  in  very  many  of  its  parts.  The  chapters 
on  -'Diseases  of  the  Bladder,"  "Prostate  Body,"  and 
'■Lithotomy,"  are  splendid  specimens  of  descriptive 
writing;  while  the  chapter  on  -Stricture"' is  one  of  the 

most  concise  and  clear  that  we  have  ever  read. ^tw 

York  Med.  Journ.,  Nov.  1876. 


-TtY  THE  SAME  AUTHOR. 

A   PRACTICAL    TREATISE    ON    FOREIGN    BODIES   IN   THE    ] 

AIR-PASSAGES.     In  1  vol.  8vo. ,  with  illustrations,  pp.  468,  cloth,  $2  75. 
jyiGELO  W  [HENRY  J.),  mTK, 

-*-'  Professor  of  Surgery  in  the  Massachxtsetts  Med.  College. 

ON    THE   MECHANISM    OF    DISLOCATION    AND   FRACTURE 

OF  THE  HIP.     With  the  Reduction  of  the  I)is!ou:ition  by  the  flexion  Method.     With 
numerous  original  illustrations.      In  one  very  handsome  octavo  volume.      Cloth,  $2  50 


Henry  C.  Lea's  Publications — (Surgery). 


2T 


CfTJ31S0N  {LEWIS  A.),  A.M.,  M.D., 

^^  Surgeon  to  the  Preshyterian  Hospiinl. 

A  MANUAL  OF  OPERATIVE  SURGERY.     In  one  very  liandsome 

royal  12mo.  volume  of  about  500  pages,  with  332  illustrations  ;  cloth,  $2  50.  {Just  Ready  ) 
Many  years  having  elapsed  since  the  appearance  in  this  country  of  any  work  devoted  exclu- 
sively to  the  operations  of  surgery,  and  the  ordinary  surgical  text-hooks  being  too  lar;re  and 
unwieldy  for  ready  consultation  and  reference,  the  author  has  thought  that  a  compact  manual 
devoted  exclusively  to  practical  operative  details,  thoroughly  illustrated,  would  sujiply  a  want 
universally  felt.  He  has  accordingly  sought  to  embody  in  the  work  a  concise  account  of  all  the 
operations  practised  at  the  present  day,  devoting  special  attention  to  the  newer  and  Ie83  fami- 
liar  ones,  copiously  illustrated  with  diagrnnis  and  figures,  many  of  which  are  original.  The 
scope  of  the  work  can  be  gathered  from  the  subjoined  very  condensed 

e,-UJs/Lls/IJ^-Eir^  <D^  COTSTTEISTTS. 
Part  I.  The  Accessories  of  an  Operatton.  Padt  II.  Ligature  of  Arteries.  Part  III. 
Amputation.  Part  IV.  Excision  of  Joints  and  Bones.  Part  V.  Neurotomy  and  Tenot- 
omy. Part  VI.  Plastic  Operations  of  the  Face.  Part  VII.  Special  Operations.  Chap. 
I.  Operations  upon  the  Eye  and  its  Appendages.  Chiip.  II.  Operations  upon  the  Ear  and  its 
Appendages.  Chap.  III.  Operations  upon  the  Mouth  and  Phaiynx.  Chap.  IV.  Operation? 
performed  upon  the  Neck.  Chapi.  V  Operations  performed  upon  the  Thorax.  Chap.  VI.  Ope- 
rations performe<l  upon  the  Abdominal  Wall,  Stomach,  and  Intestines  Chap.  VII  Operations 
upon  the  Male  Genito- Urinary  Organs  Chap.  VIII.  Operations  upon  the  Genito-Urinary 
Organs  of  the  Female.      Chap.  IX.   Miscellaneous  Operations. 


H 


0  LMES  (  TIM  0  TH  Y) ,  M. D . , 

Surgeon  to  St   George's  Hospital,  London. 

SURGERY,  ITS    PRINCIPLES    AND    PRACTICE.     In   one  hand- 

some  octavo  volume  of  nearly  1000  pages,  with  411  illustrations.     Cloth,  $6;  leather,  $7. 
(Just  Issued.) 

to  bring  it  within  its  proper  limits  has  not  impaired 
its  fiircrt  aniJ  distinctness:— ..V.  r.  Med.  Record,  April 
U,  1P76, 

It  will  be  found  a  most  excellent  epitonie  of  sur- 
gery by  tlie  geueral  pr«ctiiiouer  wliolia»  not  i  lie  time 
10  gi  ve  atteutioQ  to  more  minute  and  extended  works, 
and  to  the  medical  student.  In  fact,  we  know  of  no 
one  we  can  more  cordially  recommend.  Tlie  author 
has  succeeded  well  in  giving  a  plain  and  practical 
a-count  of  each  surgioal  injury  ami  dise«he,  and  of 
the  trentinent  wliich  is  most  coiumouly  adrisalile. 
It  will  DC)  doubt  bpcnme  a  popular  work  in  the  pro- 
fession, and  e.'specially  as  a  text-book.  — Cincmnaif 
Med.  Xews,  April,  1S76. 

In  point  of  literary  structure  we  have  no  words  but 
those  of  praise  to  write  of  Dr.  Holmes's  book.  His 
diction  is  always  graceful  and  clear,  and  he  usually 
works  with  areat  conscientiousness.  There  if  much 
independence  of  thoaght  and  a  hpaltby  disposition  to 
resist  the  tendi-ucy  to  walk  in  old  tracks  ciniply  he- 
cause  they  are  old.  On  the  whole,  he  has  done  his  work 
in  a  manner  for  which  it  wonid  be  UDgenerous  not  to 
give  him  very  high  credit  indeed. — Dublin  Journ  nf 
Med.,  Oct.  IS'76. 


Webelieveit  tobeby  farthebest  surgicsl  text-hook 
tiiat  we  have,  insomuch  as  it  is  the  complete>-t,  and 
the  one  most  thoroughly  brought  up  to  the  knowledge 
of  the  present  day.  All  who  will  give  this  book  the 
careful  perusal  that  it  deserves  aud  requires,  whe- 
ther student  or  practitioner,  will  agree  with  ns,  that, 
from  the  happy  way  iu  which  justice  is  done,  both  to 
the  principles  and  practice  of  surgery,  from  the  care 
with  which  its  pages  are  brought  up  to  modern  date, 
from  the  respect  which  is  paid  all  along  to  the  opin- 
ions of  others,  it  deserves  to  fake  the  first  place 
among  the  text-books  on  surgery.  —  Brih'.sA  Med. 
Journ.,  Dec.  2.5,  187.5. 

This  is  a  work  which  has  been  looked  for  on  both 
sides  of  the  Atlantic  with  much  interest.  Mr.  Holmes 
is  a  surgeon  of  large  and  varied  experience,  and  one 
of  the  best  known,  and  perhaps  the  most  brilliant 
writer  upon  surgical  subjects  in  England.  I',  is  a 
book  for  students — and  an  admirable  one— and  for 
the  busy  general  practitioner  It  will  give  a  student 
all  the  knowledge  needed  to  pass  a  rigid  examina- 
tion. The  book  fairly  ju>tiliesthe  high  expectations 
that  were  formed  of  it.  Its  style  is  clear  and  forcible, 
even  brilliant  at  times,  and  the  conciseness  needed 


TJAMILTON  {FRANK  H.),  M.D., 

Professor  of  Fractures  and  Di.9locations,  Ac,  in  Bellemie  Hosp.  Mtd.  College,  Neto  York. 

A  PRACTICAL  TREATISE   ON   FRACTURES  AND    DISLOCA- 

TIONS.  Fifth  edition,  revised  and  improved.  In  onelargeand  handsome  octaTovolame 
of  nearly  800  pages,  with  344  illustrations.  Cloth,  $5  75  ;  leather,  $6  75.  {Lately  fs.-tii-d.) 
This  work  is  well  known,  abroad  as  well  as  at  home,  as  the  highe.st  authority  on  its  important 
subject — an  authority  recognized  in  the  courts  as  well  as  in  the  sehool.s  and  in  practice — and 
again  manifested,  not  only  by  the  demand  for  a  fifth  edition,  but  by  arrangements  now  in  pro- 
gress for  the  speedy  appearance  of  a  translation  in  Germany.  The  repeated  revisions  which  the 
author  has  thus  had  the  opportunity  of  making  have  enabled  him  to  give  the  most  careful  con.sid- 
eration  to  every  portion  of  the  volume,  and  he  ha.s  sedulously  endeavored  in  the  present  i^.sue, 
to  perfect  the  work  by  the  aid  of  his  own  enlarged  experience  and  to  incorporate  in  it  whatever 
of  value  has  been  added  in  this  department  since  the  issue  df  the  fourth  edition.  It  will  there- 
fore be  found  considerably  improved  in  matter,  while  the  most  careful  attention  has  been  paid 
'to  the  typographical  execution,  and  the  volume  is  presented  to  the  profession  in  the  confident 
hope  that  it  will  more  than  maintain  its  very  distinguished  reputation. 

There  is  no  better  work  on  the  sohjoot  in  existence    of  its  tcn^hin;*.  but  also  by  reason  of  the  medico  leg*! 

beariugsof  tht'ca^es  of  which  it  tri'ats,  and  which  hare 
recently  hpt'n  the  subject  of  useful  papers  by  Dr  lI.Trail- 
ton  and  others.  i?sutBcientl.vobviou«  to  every  ono  The 
present  volume  seems  to  amply  fill  all  the  requisites. 
We  ran  safely  reounmcnil  it  n«  the  t>p«t  of  its  kind  in 
the  Enclish  Inmiuairo.  and  not  pxrell'-d  in  anv  other  — 

(..et;essuy  oi  uavuis  sue.  »  """ ''^ '  V Z;;^;;  '"  '"; '"^^^^^    Journ.  of  yervouf  and  Mental  /)wra«..lan  1876, 
dates,  not  merely  on  account  of  the  practical  importance  I  "  • 


28 


Henry  C.  Lea's  Publications — {Surgery). 


PRICHSEN  {JOHN  E.), 

-*-^  Professor  of  S^irgery  in  University  College,  London,  etc. 

THE  SCIENCE  AND  ART  OF  SURGERY;  being  a  Treatise  on  Sur- 
gical Injuries,  Diseases,  and  Operations.  Carefully  revised  by  the  author  from  the 
Seventh  ant  enlarged  English  Edition.  Illustrated  by  eight  hundred  and  sixty  two  en- 
gravings on  wood.  Ir  two  large  and  beautiful  octavo  volumes  of  nearly  2000  pages: 
cloth,  $8  60  ;  leather,  $10  50.      (Now  Ready.) 

In  revising  this  standard  work  the  author  has  spared  no  pains  to  render  it  worthy  of  a  continu- 
ance of  the  very  marked  favor  which  it  has  so  long  enjoyed,  by  bringing  it  thoroughly  on  a 
level  with  the  advance  in  the  .=cience  and  art  of  surgery  made  since  the  appearance  of  the 
last  edition.  To  aecumplish  this  has  required  the  addition  of  about  two  hundred  page"  of  text, 
while  the  illustrations  have  undergone  a  marked  improvement.  A  hundred  and  fifty  additional 
woodcuts  have  been  inserted,  while  about  fifty  other  new  ones  have  been  su))Stituted  ior  figures 
which  were  not  deemed  satisfactory.  In  its  enlarged  and  improved  form  it  is  therefore  pre- 
sented with  the  confident  aiiticijiation  that  it  will  maintain  its  position  in  the  front  rank  of 
text-boi'ks  for  the  student,  and  of  works  of  reference  for  the  practitioner,  while  its  exceedingly 
moderate  price  places  it  within  the  reach  of  all. 


The  seveuih  pdition  is  before  the  world  as  the  last 
wor.l  ot  surgical  t-cience.  There  may  be  inouographs 
whicli  excel  it  iipm  certain  puinlK,  but  as  a  con- 
spectu.s  upon  surgical  piinciples  aud  practice  it  is 
unrivalled.  It  will  well  reward  prHCliliouer.s  to 
read  it,  for  it  has  been  a  peculiar  prorince  of  Mr. 
Erichsen  to  demoustrate  the  absolute  interdepend- 
ence of  medical  aud  surgical  science  We  ueod 
scarcely  add,  in  conclusion,  that  wh  heartily  com- 
mend tlie  work  to  siudeuts  that  they  may  be 
grounded  in  a  sound  faith,  and  to  practitioners  as 
an  invaluable  gu.de  at  the  bed.-.ide.— ^m  Practi- 
tionur,  April,  1S7S. 

It  is  no  i  ile  compliment  to  say  that  this  is  the  be.st 
edition  Mr.  Erichsen  has  ever  produced  of  his  well- 
known  book.  Besides  inheriting  the  virtues  of  is 
predecessors,  it  possesses  excellences  quite  its  own.' 
Having  staled  that  Mr.  Erichsen  his  incorpoialed 
into  this  edition  every  recent  improvement  in  the 
science  and  art  of  surgnry,  it  would  be  a  Hupereroga- 
tion  to  give  a  detailed  criticism.  In  short,  we  un- 
hesitatingly arer  that  we  know  of  uo  other  single 
work  wlipre  tue  student  and  practitioner  can  gain  at 
once  so  clear  an  insight  iuto  the  priociples  of  surgery, 
and  so  complete  a  knowledge  of  the  exigeiicies  of 
surgical  practice.— Z/Owtion  Lancet,  Feb.  It,  1S7S. 

For  the  past  twenty  years  Eiichsen's  Surgery  lias 
maint  ai  lied  its  place  as  t  lie  lea  ding  text- book,  not  only 
in  this  country,  but  in  Great  Briiaio.  Thut  it  is  able 
to  hold  its  ground,  is  abundaally  proven  by  the  tho- 
rougluiess  with  which  the  present  edition  has  bean 
revised,  and  by  the  large  amount  of  valuable  mate- 
rial tha'  has  b>ea  added.  Aside  fiom  this,  f  ne  hun- 
dred aud  titty  new  illustrations  have  been  inserted, 
incluiliug  quite  a  number  of  tuicroscopical  appear- 
ances of  pith  jljgical  processes,     do  mirked  is  this 


change  for  the  better,  that  the  work  almost  appears 
as  an  entirely  new  one. — Med.  Record,  Feb.  28,  1S78. 

Of  the  many  treatises  on  Surjrery  which  it  lias  been 
our  task  to  stuily .  or  our  pleasure  to  read,  there  is  none 
which  in  all  points  has  satisfied  us  so  well  as  the  classic 
treatise  of  Krichsen.  His  poli.slied,  clear  style,  his  free- 
dom from  prejudice  and  hobbies,  bis  unsurpassed  grasp 
othis  suliject,  and  vast  clinical  experience,  qualify  him 
admirably  to  write  a  model  text-hook.  Wheu  wowish, 
at  the  least  cost  of  time,  to  learn  the  most  of  a  topic  ia 
surgery,  we  turn,  by  preference,  to  his  work.  It  is  a 
plea.sure,  therelore,  to  sec  that  the  appreciation  of  it  is 
o;eneral,  and  has  led  to  the  appearance  of  anoiher  edition. 
— Mud.  and  Swg.  Jiepurtn;  Feb.  2,  1S78. 

Notwithstandiii};  the  increase  iu  size,  we  observe  that 
much  old  matter  has  been  omitted.  The  entire  work 
has  been  thorouj^hly  written  up,  and  not  merely  amend- 
ed by  a  few  extra  chapters  A  {;reat  improvement  has 
been  made  in  the  illustrations.  One  liuudred  and  fifty 
new  ones  have  been  added,  and  many  of  the  old  ones 
have  been  redrawn.  The  author  highly  appreciates  the 
favor  wiih  which  his  work  has  been  received  by  Ameri- 
can suricepns,  and  has  endeavored  to  render  his  latest 
edition  more  than  ever  worthy  of  their  approval.  That 
he  has  .succeeded  admirably,  must,  we  think,  he  the 
peneral  opinion.  We  heartily  recommend  the  book  to 
both  stuileut  and  pracLitiouer. — N.  i'.  Med.  Journal, 
Feb.  1878. 

It  is  entirely  unnecessary  for  us  to  attempt  to  add,  by 
our  praises,  one  jot  to  the  established  reputation  of 
Ericliscn's  Science  and  Art  of  Surjjery.  It  has  long 
been  a  favorite  text-book  and  authority  in  this  country 
as  Wdll  as  iu  Knulaud  aud  on  the  Continent,  and  the 
present  edition  can  but  add  to  its  popularity. — Ohio 
Med.  Recorder,  Jan.  1878. 


jyRUITT  {ROBERT),  M.li.C.S.,  ^c. 

THE  PRINCIPLES  AND  PRACTICE  OF  MODERN  SURGERY. 

A  new  and  revised  American,  from  the  eighth  enlarged  and  improved  London  edition.  Illus- 
trated with  four  hundred  and  thirty-two  wood  engravings.  In  one  very  handsome  octavo 
volume,  of  nearly  700  large  and  closely  printed  pages,  cloth,  $4  00  j  leather,  $5  00. 


All  that  the  surgical  student  or  practitioner  could 
desire. — Dublin  Quarterly  Journal. 

It  is  a  most  admirable  book.  We  do  not  know 
when  we  have  examined  one  with  more  pleasure. — 
Boston  Med.  and  Surg.  Journal. 

In  Mr.  Druitt's  book,  though  containing  only  some 
seven  hundred  pages,  both  the  principles  and  the 


practice  of  surgery  are  treated,  and  go  clearly  and 
perspicuously,  as  to  elucidate  every  important  topic. 
We  aave  examined  the  book  most  thoroughly,  and 
can  say  that  this  success  is  well  merited.  His  book, 
moreover,  possesses  the  inestimable  advantages  oif 
having  the  subjects  perfectly  well  arranged  and  clas- 
lified,  and  of  being  written  in  a  style  at  once  clear 
md  succinct. — Am.  Journal  of  Med.  Sciences. 


B 


RTANT  {THOMAS),  F.R.C.S., 

Surgeon  to  Ouy's  Hospital. 

THE  PRACTICE  OF  SURGERY.     Second  American,  from  the  Sec- 

ond  and  Revised  English  Edition.     With  over  Five  Hundred  Engravings  on  Wood.     In 
one  large  and  very  handsome  octavo  volume  of  nearly  1000  pages.     {Shortly.) 


ASHTON  ON  THE  DISEASES,  INJURIES,  AND  MAL- 
FORMATIONS OF  THE  RECTUM  AND  ANUS  ;  with 
remarks  on  Habitual  Constipation.  Second  Aineri- 
cau,  from  the  fourth  and  enlarged  London  Edition. 
With  illustrations.  In  one  8vo.  vol.  of  2S7  pages, 
cloth,  $3  25. 


SARGENT  ON  BANDAGING  AND  OTHER  OPERA- 
TIONS OF  MINOR  SURGERY.  New  edition,  with 
an  additional  cliapter  on  .Military  .Surgery.  One 
12mo.  vol.  of  3S3  pages,  with  181  wood-cuts.  Clotb, 
$1  75. 


Henry  C.  Lea's  Publications— ( Ox)hthalmology) . 


29 


G' 


OSS E LIN  (L.), 

Professor  0/ Clinical  Surgery  in  the  Faculty  of  Medicine,  Paris,  etc. 

CLINICAL  LECTURES  ON  SURGERY.     Delivered  at  the  Ilospifnl  of 

La  Charite.  Translated  from  the  French  by  Lewis  A.  Stimson,  M.l).,  Sureeon  to  the 
Presbyterian  Hospital,  New  York.  With  illustrations.  In  one  neat  octavo  volume  of 
360  pages  j  cloth,  $2  60.      (Nou,  Ready.)     From  the  Medvcal  l^e^sa^^iTLihVry 

SVMMARY  OF  co:stj:nts. 

PART  I.  Surgical  Diseases  of  Toorn.  8  Lect. 

"     II    Fractckes  OF  THE  Limbs.  18    " 

'.'III.  Traumatic  Osteitis  AND  Neckosis    2    " 


PART  IV.   Traumatic   Fever,  SEPTiCy'EMiA 

A.Ni)  Pwemia.  '  4  Lect 

PART  V.  Diseases  of  the  Aktici'lations.    7    " 
"      VI.  PHLEaMo.v,AB.scEss,  A.vD  Fistula.  3    " 
It  will  be  seen  from  this  brief  abstract  of  the  contents  that  these  Lectures  treat  of  subjects 
which  are  of  daily  intere.st  to  the  vmctitioner,  while  some  of  them  hardly  receive  in  the  text- 
books the  attention  which  their  importance  deserves. 


B 


ROWNE  [EDGAR  A.), 

Suroeon  to  the  Liv:'rpnoJ  Eye  nnri  V.nr  Infirmary,  and  tn  the  Dispensary  for  Skin  Disrates 

HOW  TO  USE  THE  OPHTHALMOSCOPE.     Being  Elenientan  In- 

structions  in  Ophthalmoscopy,  arriin^ed  for  the  Use  of  Students.    wTth  thirly-five  illustra- 
tions.    In  one  small  volume  royal  ]2mo.  of  120  pages  :  cloth,  $1.     (J\'o7v  Heady.) 
This  capital  little  work  i-bould  be  iu  the  haudt.  of  i  stnuiient  and  the  snggestionK  to  aid  in  iulerpreline 
ev,  ly  medical  s-tudent.  aud  we  Lad  almostsaid  every  |  what  is  seen. — Dttroit  Wed.  Jotirn.,  ^ov.   1877 
general  jiractitioner.     Its  explanation  of  llje  optic  il  i      'i'l^  ;„f,  „„,„»;.„  :      ■        •    "  '    ■      , 

prin.iples  on  which  the  ophtlialnio.^cupe  i.  fonuded,     ,ko  ^dh^v  ^^M  ^' V'.'"' ''rT '"'"'"'"' *'"'vV'^  "'=•■'' 
is  so  Clear  and  simple    that  the  mo..t  Uupid  reade^    thTdilc™  ton.Ue  manner,    .Man.v  .f 

could  scarcely  fail  of  understanding  them.    Equally     i,^' ^"*;  "i;;  t^^^  >^^  .      "''"."'■"■'""'    *""* 

satislactory  are  the  directions  for  the  use  of  the  in    !  ^SinZZ  jluZ  '  ''^  mMrucUve.- 

pARTER  [R.  BRUDENELL\~F.KC^, 

^^  Oj/'it/irilmic  Surgeon  lo  St.  George  s  Hospital,  ttc. 

A  PRACTICAL  TREATISE  ON  DISEASES  OF  THE  EYE.    Edit- 

ed,  with  test-types  and  Additions,  by  John  Green,  M.D.   {of  St.  Louis,  jMo.).     In  one 

handsome  octavo  volume  of  about  500  pages,  and  124  illustrations.     Cloth,  $3  75.     (Just 

Issued.) 

Dr.  Green,  whose  reputation  and  experience  in  this  department  are  well  known,  has  given  this 

work  a  very  careful  revision,  and  has  introduced  much  matter  which  will  be  found  of  importance 

to  the  practitioner.     As  his  system  of  test-types  is  the  one  recommended  by  the  authur,  they 

have  been  inserted  in  the  volume  in  a  shape  which  will  admit  of  their  being  detached  and 

mounted  for  convenient  office  use. 

These  test-types,  on  a  sheet  for  mounting,  can  be  had  separate,  price  25  cents. 
It  would  be  difficult  for  -Mr.  Carter  to  write  an  uuin-  .  in  view,  and  presents  the  subject  iu  a  clear  niiU  concii-e 
Btructive  book,  and  impossible  for  him  to  write  au  uu-  I  manner,  easy  of  conipreliensiun,  aud  hence  the  more 
interesting  one.  Even  ou  subject.^  with  which  he  is  ni>t  valuable.  Me  would  especially  cuiuuieiid,  huwover,  »4 
bound  to  be  familiar,  hecandi.-cour.su  with  a  rare  degree  worthy  of  liit;h  praise,  the  manner  iu  which  llie  thern- 
ot  clearness  and  effect.  Our  readers  will  therefore  uot  I  peutics  of  dL-ease  of  the  e>e  is  elaborated,  for  here  the 
be  surprised  to  learu  that  a  work  by  him  on  the  I'isea.-es  j  author  is  particularly  clear  aud  practical,  wliertr  other 
of  the  Ey<^  makes  a  very  valuable  addition  to  ophthal-  ]  writers  are  unfortunately  loo  often  deticienl.  'I  lie  liuiil 
niic  literature.  .  .  .  The  book  will  remain  one  useful  |  cliapier  is  devoted  to  a  discus!-iou  ot  llir  u.^es  and  .-flcc- 
alike  to  the  general  and  the  special  practitioner.  Kot  tion  of  spectacles,  and  is  ailmirably  compact.  pIhIii,  and 
tliK  least  valuable  result  which  we  expectfrom  it  is  that  ,  useful,  especially  the  purapriiphs  on  tlie  Ireatuuiil  of 
it  will  to  some  coui-iderubJe  extent  aospeciiilize  this  bril-  presbyopia  and  myopia.  In  c(lnclu^ion,  our  thanks  aro 
liant  department  of  medicine.— iortdow  Lanctt,  Oct.  30,  due  the  author  for  many  u,-eful  hints  iu  the  t;real  sub- 
187S.  ject  of  ophthalmic  Hur^ery  and  therapeutics,  a  CelU 

It  is  with  creat  pleasure  that  we  can  endorse  the  work     ^j'-^--^  f  '«'«  J^'^'lf  ^.K'':""  \V^ 'V-"'*,  ""T  V',;''"'''' 
as  a  most  valuable  contribution  to  ,,ractical  ophthal- I  ;;^;«,'/'-o'^  »"'"»«"! '=1^'^^--^'^'"  ^  "'•*■■ ''''^'<^«' ^ 
mology.    Mr.  Carter  never  deviates  fioui  the  end  he  has  ,  ^^^-  -•>)  ^   '    ■ 

ELLS  {J.  SOELBERO), 

Professor  of  Ophthalmology  in  King's  College  Hospital,  4c. 

A  TREATISE    ON    DISEASES  OP  THE  EYE.      Third  Americar, 

from  the  Fourth  and  Revised  London  Edition,  with  additions  ;  illustrated  with  numerous 
engravings  on  wood,  and  six  colored  plates.  Together  with  selections  from  the  Test-typf» 
of  Jaeger  and  Snellen.    In  one  large  and  very  handsome  octavo  volume.     (PrrjHirhig.) 

^TA  URENCE  [JOHN  Z.),  F.  R.  C.S., 

Editor  of  the  Ophthalmic  Review,  *c. 

A  HANDY-BOOK  OF   OPHTHALMIC   SURGERY,  for  the  use  ol' 

Practitioners.  Second  Edition,  revised  and  enlarged.  With  numerous  illustrations.  In 
one  very  handsome  octavo  volume,  cloth,  $2  76. 

A  WSON  [GEORGE),  F.  R.  C.  S.,  Evgl, 

Assistant  Surgeon  to  the  Royal  London  OphihMmic  Bospita  I    Mnorfields ,  *<" . 

INJURIES  OF  THE  EYE,  ORBIT,  AND  EYELIDS:  their  Imme- 

diate  and  Remote  Effects.      With  about  one  hundred  illustration!:.     In  one  very  hand 
some  octavo  volume,  cloth,  $3  50. 


w 


L 


30 


Henry  C.  Lea's  Publications — {^Medical  Jurisprudence). 


'DURNETT  (CHARLES  H.),  M.A  ,  M.D., 

-*-'  Aural  Surg,  to  the  Pre.ish.  Hasp.,  Surgeon-in-i.hargeofth.eInfir.forDis.  of  the  Ear,  Phila. 

THE    EAR,    ITS    ANATOMY,    PHYSIOLOGY,    AND    DISEASES. 

A  Practical  Treatise  for  the  Use  of  Medical  Students  and  Practitioners.      In  one  hand- 
some octavo  volume  of  615  pages,  with  eighty-seven  illustrations  :  cloth,  $4  50;   leather, 
$5  50.      {Just  Ready.) 
Recent  progress  in  the  investigation  of  the  structures  of  the  ear,  and  advances  ma'^e  in  the 
modes  of  treating  its  diseases,  would  seem  to   render  desirable  a  new  work  in  which  all  the  re- 
sources of  the  most  advanced  science  should  b«  placed  at  the  dispotial  of  the  practitioner.     This 
it  has  been  the  aim  of  Dr.  Burnett  to  accomplish,  and  the  advantages  which  he   has  enjoyed  in 
the  special  study  of  the  subject  are  a  guarantee  that  the  result  of  his  labors  will  prove  of  service 
to  the  profession  at  large,  as  well  as  to  the  specialist  in  this  department. 

As  the    title  of  the  work   indicates,  tliis   volume    ;   the   medical   student  iind  general   practitioner,  this 


treats  of  the  anatomy  and  physinlogy  of  the  ear,  as 
well  an  of  its  diseases,  and  the  author  has  taken 
special  pains  to  nial^e  this  dillicuU  and  complicated 
matter  thoroughly  clear  and  intelligihle.  The  book 
is  designed  especially  for  the  use  of  t-tudents  and 
general  practltioneis,  and  places  at  their  disposal 
much  valuable  material,  ^uch  a  book  as  the  pre- 
sent one,  we  think,  has  long  be^n  needed,  and  we 
may  congratulate  the  author  on  his  success  in  fill- 
ing the  gap.  Both  student  and  practitioner  can 
study  the  work  with  a  great  deal  of  benefit.  It  is 
profusely  and  beautifully  illu.slraled. — y.  Y.  Uoh- 
pital  Gazette.,  Oct   l.i,  Ibf?. 

The  medical  student  and  general  practitioner 
have  long  felt  the  need  of  a  book  of  this  character  on 
an  organ  so  little  understood  and  yet  so  important 
as  the  ear.  The  author  has  presented  in  ibe  volume 
clearly  but  concisely  the  groat  advances  ivliicli  have 
been  made  of  late  yearsiu  otology  and  has  iiidicaled 
the  direction  in  which  further  researches  can  be 
moat  profitably  carried  on  The  work  is  divided 
into  two  pares.  In  I'art,  I.  the  auatotny  and  physiol- 
ogy of  the  ear  are  minutely,  yet  pxplicitly,  detailed 
in  a  manner  not  lo  be  found  in  any  of  the  ordinary 
text-b'ioks.  In  Part  II  the  disea.^es  and  treatment 
of  the  ear  are  fully  and   praclically  presented.     To 


work  is  indi.«peusable,  and  «-ill  not  he  found  void  of 
iulorest  to  the  specialist  — Maryland  Med.  Journ., 

Nov  1S77 

The  appearance  of  this  book  is  another  proof  of  the 
rapidly  increasing  amount  of  hone^'t,  valuable  work 
that  is  now  being  done  in  the  various  branches  of 
medical  sciencein  tliis  country.  Dr.  Burnett  is  to  be 
comuiendod  for  having  written  the  best  book  on  the 
subject  in  the  English  language,  and  especiaUy  for 
the  care  and  attention  he  lias  gi ren  to  the  scientific 
side  of  the  subject. — N.  Y.  Med.  Journ.,  Dec.  1877. 

There  is  probably  no  other  book  of  the  kind  in 
the  English  language  which  contains  so  concise  and 
yet  so  complete  an  account  of  the  numerous  dis- 
eases to  which  the  ^ar  is  liable.  Wo  can  safely  pre- 
dict that  every  intelligent  medical  man  who  takes  . 
the  trouble  to  make  himself  f  miliar  with  the  lead-  ' 
ing  facts  concerning  this  class  of  disease,  as  given 
by  Or.  Hurnett,  will  not  only  admit  that  the  time 
thus  employed  was  far  from  being  wasted,  but  that 
the  earnest  labors  of  Ot.ilogisis  within  tho  last  few 
years  have  taken  away  ilia  sting  of  reproach  con- 
tained in  the  hackneyed  plir-ise  that ''nolbing  can 
be  got  out  of  the  ear  but  foes  and  wax."— Canarfa 
Med.  and  Surg.  Joxi.rn.,  Kov.  l!-77. 


T 


'AY LOR  (ALFRED  S.),  M.D., 

Lecturer  on  Med.  Jurinp.  and  Chemistry  in  Guy'n  Hospital. 

POISONS  IN  RELATION  TO  MEDICAL  JURISPRUDENCE  AN] 

MEDICINE.     Third  American,  from  the  Third  and  Revised  English  Edition.     In  on* 
large  octavo  volume  of  850  pages  ;  cloth,  $5  50  ;  leather,  $6  50.      {J7(st  Issued.) 


The  present  is  based  npon  the  two  previous  edi-  i 
tions  ;  "but  the  complete  revision  rendered  necessaiy 
by  time  has  converted  it  into  a  new  work."  Thi.s  | 
statement  from  tl.'e  preface  contains  all  that  it  is  de- 
sired to  know  in  reference  to  the  new  edition.  The 
works  of  this  author  are  already  in  the  library  of 
every  physician  who  is  liable  to  be  called  upon  for 
medico-le:,'al  testimony  (and  what  "nets  not?),  so  that 
all  that  is  required  to  be  known  about  the  present 
book  is  that  the  author  has  kept  it  abreast  with  the 
times  What  makes  it  now,  as  always,  especially 
valuable  to  the  practitioner  is  its  conciseness  and 
practical  character,  only  those  poise n.ons  substances 


being  described  which  give   rise  to  Isgal  iiivesliga 
tious.— ry»«  Clinic,  Nov.  6,  1875. 

Dr.  Taylor  has  brought  lobear  on  the  compilation 
of  this  volume,  stjres  of  learning,  experience,  antf 
practical  acquaintance  with  bis  subject,  probably  fat 
beyond  what  any  other  living  authority  on  toxicol>j 
ogy  could  have  amassed  or  utilized.  He  has  fullj 
sustained  his  reputation  by  tho  consuniiiiate  skilS 
and  legal  acumen  be  has  displayed  in  the  arranged 
ment  of  tlie  subject-matter,  and  the  result  is  a  worl 
on  Poisons  which  will  be  indispensable  to  every  stn^ 
dent  or  practitioner  in  law  and  medicine — 2'he  Ihib 
lin  Journ.  cf  Med  Set.,  Oct.  1870. 


jor  THE  SAME  AUTHOR. 

MEDICAL  JURISPRUDENCE.    Seventh  American  Edition.     Edite( 

by  John  J.  Reese,  M.D.,  Prcf.  of  Med.  Jurisp.  in  the  Univ.  of  Penn.     In  one  largj 

octavo  volume  of  nearly  900  pages.     Cloth,  $5  00;  leather,  $G  00.     (Lately  Issued.) 

To  the  members  ofthe  legal  and  medical  profession,  ,  best  authority  on  this  specialty  in  our  language.     On 

it  is  unnecessary  to  say  anything  commendatory  of  |  this  point,  however,  we  will  say  that  we  consider  DrJ 

Taylor's  Medical  Jurisprudence.    We  might  as  well  I  Taylor  to  bo  the  safest  medico-legal  anlhority  to  fol| 

undertake  to  speak  of  the  merit  of  Chitty's  Plead-    low,  in  general,  with  which  we  are  acquainted  in  anj 


ings. — Chicago  Legal  Naws,  Oct.  16,  1873. 

It  is  beyond  question  the  most  attractive  as  well 
as  most  reliable  manual  of  medical  jurisprudence 
published  in  the  English  language. — Am.  Journal 
of  Syphilography,  Oct.  1873. 

It  is  altogether  superfluous  for  us  to  offer  anything 
in  behalf  of  a  work  on  medical  jurisprudence  by  an 
author  who  isalmost  universally  esteemed  to  be  the 


language.  —  Va.  Clin.  Record.  Nov.  Ib73. 

Thislastedition  ofthe  Manual  is  probably  the  besti 
of  all,  as  It  contains  more  material  and  is  worked  npf 
to  the  latest  views  of  the  author  as  expressed  in  th«J 
last  edition  of  the  Principles.     Dr.  Reese,  the  editor 
of  the  Manual,  has  done  everything  to   make  hi^ 
work  acceptable  to  his  medical  countrymen. — N. 
Med.  Record,  Jan.  1.^,  1874. 


JOr  THE  SAME  AUTHOR. 

THE  PRINCIPLES  AND  PRACTICE  OF  MEDICAL  JURISPRU- 
DENCE. Second  Edition,  Revised,  with  numerous  Illustrations.  In  two  large  octavo 
volumes,  cloth,  $10  00;  leather,  $12  00 

This  great  work  is  now  recognized  in  England  as  the  fullest  and  most  authoritative  treatise  on 
every  department  of  its  important  subject.  In  laying  it,  in  its  improved  form,  before  the  Ameri- 
can profession,  the  publisher  trusts  that  it  will  assume  the  same  position  in  this  country. 


iMJ 


Henry  C.  Lea's  Publioatione — (Miscellaneous).  31 


rp  HO  MP  SON  [SIR  HENRY), 

•*-  Sv.rgeon  ond  PrnfeKfior  of  OUnical  Surgery  to  Univemity  Oolleg>-  Hospital 

LECTURES  ON  DISEASES  OF  THE  URINAKY  ORGANS.    WitL 

illustrations  on  wood.  Second  American  from  the  Third  English  Edition.  In  one  neat 
octavo  volume.     Cloth,  $2  25.     (Just  hsned.) 

■D  T  THE  SAME  A  UTHOR .  -_ . 

ON  THE  PATHOLOGY  AND  TREATMENT  OF  STRICTURE  OF 

THE  URETHI5A  AND  URINARY  FISTULA.  With  plates  and  wood-cuts.  From  the 
third  and  revised  English  edition.  In  one  very  handsome  octavo  volume,  cloth,  $3  50. 
(Lately  Publistied.) 

■nr  THE  SAME  AUTHOR. 

THE  DISEASES   OF   THE  PROSTATE,  THEIR   PATHOLOGY 

AND  TREATMENT.  Fourth  Edition,  Revised.  In  one  hands.>me  Svo.  vol.  ol  355  page!<, 
with  13  piates,  plain  and  colored,  and  illustrations  on  wood.    Cloth,  $3  75.    (Just  hsuul.) 

rrUKE  [DANIEL  HACK),  Jl.IX, 

-*  Joint  author  of  "The  Manual  of  Psychological  Medicine,^^  Ac. 

ILLUSTRATIONS  OF  THE  INFLUENCE  OF  THE  MIND  UPON 

THE  BODY  IN  HEALTH  AND  DISEASE.  Designed  to  illu.^trate  the  Action  of  the 
Imagination.    In  one  handsome  octavo  volume  of  416  pages,  cioth,  $3  26.    (Lately  Issw.d. ) 

pLANDFORD  [G.  FIELDING),  M.D.,^R.  C.P., 

■*-^  Lecturer  on  Psychological  Medicine  at  the  School  of  St.  George's  Hospital,  <fcc. 

INSANITY  AND  ITS  TREATMENT:  Lectures  on  the  Treuimeui, 

Medical  and   Legal,  of  Insane  Patients.     With  a  Summary  of  the  Laws  in  force  in  the 
United  States  on  the  Confinement  of  the  Insane.     By  Isaac  Ray,  M.  D.     In  one  very 
handsome  octavo  volume  of  471  pages;  cloth,  $3  25. 
It  satisfies  a  want  which  must  have  beeu  sorely    ictually  aeea  in  practice  and  ihe  appropriate  treat- 
felt  by  the  busy  general  praclitloners  of  this  country.  I  ment  fur  them,  we  tind  m  Dr.  Blaudl'ord  .-*  wurlt  a 
It  takes  the  form  of  a  manual  of  clinical  descripliou  i  considerable  advance  over  previous  wniiugs  on  the 
of  the  various  forms  of  insanity,  with  a  descripliou    subject.     His  pictures  of  the  various  forms  of  mental 
of  '.he  mode  of  examining  persons  suspected  of  in-    disease  are  so  clear  and  good  that  uo  reader  can  fail 
sanity.     We  call  particular  attention  to  this  feature  I  ,o  be  .-truck  with  their  nuperioriiy  to  those  given  in 
of  the  book,  as  giving  it  a  unique  value  to  the  gene-  |  irdinary  mannals  in  the  English  language  or  (so  far 
ral  practitioner.    If  we  pass  from  theoretical  conside-    as  our  own  reading  extends}  in  any  other. — Lomt'in 
rations  to  descriptions  of  the  varieties  of  insanity  as  )  Practitioner,  b'eb   1871. 


f  EA  [HENRY  C). 

SUPERSTITION    AND    FOaCE:    ESSaYS    ON    THE   WAGER   Of 

LAW,  THE  WAGER  OF  BATTLE,  THE  ORDEAL,  AND  TORTURE.  Third  Revised 
and  Enlarged  Edition.  In  one  handsome  royal  12mo.  volume  of  about  550  pages. 
(Shortly.) 

A  few  notices  of  the  previous  edition  are  appended. 

We  know  of  no  single  work  which  contains,  in  oo  i  interesting  phases  of  human  society  and  progresB.  . 
•mall  a  compass,  so  much  illustrati  ve  of  the  strange.- 1  The  fulness  and  breadth  with  which  he  has  carried 
operations  of  the  human  mind.  Foot-notes  give  the  out  his  comparative  survey  of  this  repulsive  field  of 
authority  for  each  statement,  showing  vast  research  |  history  [Torture],  are  such  as  to  preclude  our  doing 
and  wonderful  industry.  We  advise  our  couyVcrtA  j  justice  to  the  work  withiu  our  present  limits.  Bal 
t )  read  this  book  and  ponderits  teachings. — Chicago  \  here,  as  throughout  the  volume,  there  will  bo  found 
Med.  Journal,  Aug.  1S70.  a  wealth  of  illustratiou  and  a  critical  gra^p  of  the 

As  a  work  of  curious  inquiry  on  certain  outlying  '  Philosophical  import  of  facts  which  will  reader  Mi 
points  of  obsolete  law,  -  Superstition  and  Force'"  it  !  f-^a  «  labors  ol  sierl.ug  value  to  the  h.sloncai  sea- 
one  of  the  most  remarkable  books  we  have  met  with.  |  dsat.- London  Saturday  R^^iew,  Oct.  b,  lS-0. 
—London  Athenaura,  Hov.  S,  1S66.  I      ^g  a  book  of  ready  roforeuce  ou  the  sabject,  it  Is  of 

He  has  thrown  a  great  deal  of  light  upon  what  must  ]  the  highest  v&lMe.—  WettmingterRKOieto,  Oct.  1S«7. 
be  regarded  as  one  of  the  most  instructive  as  well  as  | 


■or  THE  SAME  AUTHOR,    (tate'.y  Puhli.ihed.) 

STUDIES  IN  CHURCH  HISTORY— THE  RISE  OF   THE  TEM- 
PORAL POWER— BENEFIT  OF  CLERGY— EXCOMMUNICATION.   In  one  large  royal 
I2mo.  volume  of  516  pp.;  cloth,  $2   75. 
The  story  was  never  told  more   calmly  or  with  ,  literary  phenomenon  that  the  head  of  one  of  the  flrei 
greater  learning  or  wiser  thought.    We  doubt,  indeed,     American  houses  is  also  the  writer  of  some  of  its  mo»l 
If  any  other  study  of  tbis  field  can  be  compared  with  I  original  hoo^Ln.— London  Attitiiaiim,  Jan.  7,  1S71. 
this  for  clearness,  accuracy,  and  power. —  Chicago  '      jf,.   j^^^  h^s  done  groai  honor  to  himnelf  and  tbii 
Examiner,  Dec.  1870.  1  country  by  the  admirable  works  he  ban  written  on 

Mr.  Lea's  latest  work,  "Studies  in  Church  History."  [  ecclesiologicaland  cognate  subjects.  We  ha  ve.il  ready 
fully  sustains  the  promise  of  the  first.  It  deals  with  !  had  occasion  to  coimuend  his  "Superstition  aud 
three  subjects— the  Temporal  Power,  Benefit  of  Force"  and  his  •*  History  of  Sacerdotal  Celibacy.' 
Clergy,  and  Excommunication,  the  record  of  which  The  present  volume  is  fully  as  adniiruMe  In  its  me- 
has  a  peculiar  importance  for  the  English  student,  and  thodof  dealing  with  topict.  and  in  tho  thoroaghneivt— 
Is  a  chapter  uu  Ancient  Law  likely  to  be  regarded  as  ,  a  quality  so  frequently  lacking  in  American  author*— 
flnal.  Wo  can  hardly  passfrom  our  mention  of  such  ,  with  which  they  are  investigated.— y.  Y.  Journal  <f 
works  as  tiiese— with  which  that  on  "Sacerdotal  Psyeliol  Medicine,  JaXj,  ISIO. 
Celibacy"  should  be  included— without  noting  the 


32 


Henry  C.  Lea's  Publications. 


INDEX   TO    CATALOGUE, 


Amerlcau  Journal  of  the  Medical  Sciences 

Abstract,  Jlonthly,  of  the  Med.  Sciences 

Allen's  Anatomy 

Anatomical  Atlas,  by  Smith  ii^d  Horner 

Ashton  on  the  Kectum  and  Anns  . 

Attfield's  Chemistry      .... 

Ashwell  on  Diseases  of  Females  . 

Ashhur.st's  Surgery  .... 

Browne  uu  Opiithalmoscope    . 

Burnett  on  the  Ear 

Barnes  on  Diseases  of  Women 

Bellamy's  Surgical  Anatomy 

Bryant's  Practical  Surgery     . 

Bloxam's  Chemistry       .... 

blandfovd  on  Insanity    .... 

Basham  on  Renal  Diseases    . 

Brinton  on  the  Stomach 

Bigelow  on  the  Hip         .... 

Barlow's  Practice  ol  Medicine 

Bowman's  (John  E.)  Practical  Chemistry 

Bowman's  (John  E.)  Medical  Chemistry 

Bristowe's  Practice  .... 

iinmstead  on  Venereal  .... 

Bumstead  and  CuUerier's  Atlas  ofVenereal 

Carpenter's  Human  Physiology   . 
Carpenter  on  the  Use  and  Abuse  of  Alcoho 

Cornil  and  Ranvier  .... 

Carter  on  the  Eye 

Cleland's  Dissector  .... 

Clowes'  Chemistry  .         .         .        .         • 

Century  of  Am«ricaD  Medicine 

Chadwick  on  t)isea"e»  of  Women  . 

Charcot  ou  the  is'ervous  System 
Chambers  on  Diet  and  Kegimen     . 
Chambers's  Restorative  Medicine 
Christison  and  Griffith's  Dispensatory 
C  hurchill's  System  of  Midwifery  . 
Churchill  on  Puerperal  Fever 
Condie  on  Diseases  of  Children     . 
Cooper's  (B.  B.)  Lectures  on  Surgery  . 
CuUerier's  Atlas   of  Venereal  Diseases 
Cyclopedia  of  Practical  Medicine. 
Dalton's  Human  Physiology 
Davis's  Clinical  Lect<irps 

Dewees  on  Diseases  of  Females    . 
Drnitt's  Modern  Surgery 
Dnnglisou's  Medical  Dictionary    . 
Dunglisoa's  Human  Physiology    . 
Erichsen's  System  of  Surgery 
Farquharson's  Therapeutics    . 
Fenwick's  Diagnosis        .... 
Flint  on  Respiratory  Organs  . 

Flint  on  the  Heart 

Flint's  Pr;ictice  of  Medicine  . 

Flint's  Essays 

Flint  on  Phthisis 

Flint  on  Percussion  .... 

Fothergill's  Handbook  of  Treatment     . 

Fothergiirs  Antagonism  of  Therapeutic  Age 

fuwnas's  Elementary  Chemistry  . 

Fox  on  Diseases  of  the  Skin   . 

Fuller  on    the  Lungs,  &c. 

Green's  Pathology  and  Morbid  Anatomy 

Gibson's  Surgery 

Gluge's  Pathological  Histology,  by  Leidy 

Gray's  Anatomy 

Griffith's  (R.  E.)  Universal  Formulary 
Gross  on  Urinary  Organs 
Gross  on  Foreign  Bodies  in  Air-Passages 
Gross's  Principles  and  Practice  of  Surgery 
Gosselin's  Clinical  Lectures  on  Surgery 
Eamilton  on  Dislocations  and  Fractures 
Hartshorne's  Essentials  of  Medicine     . 
Hartshorne's  Conspectu."  of  the  Medical  Scie 
Hartshorne's  Anatomy  and  Physiology 
Hamilton  on  Nervous  Diseases 
Heath's  Practical  Anaiomy    . 
Hoblyn's  Medical  Dictionary 

Hodge  on  Women 

Hodge's  Ohstetrics 

Hodge's  Practical  Dissections 
aoUand's  Medical  Notes  and  Reflections 


ts 


PA  (IE 
1 


Holmes's  Surgery    .... 

Holden's  Landmarks 

iorner's  Anatumy  and  Histology 

Hudson  on  Fever     .... 

4ill  on  Venereal  Diseases 

lillier's  Handbook  of  Skin  Diseases 

Jones  (C.  Handfield)  on  Nervous  Disorde 

Kirkes'  Physiology 

Kuapp's  Chemical  Technology 

Lea's  Superstition  and  Force 

Leas  Studies  in  Church  History 

Lee  OB  Syphilis 

Lincoln  on  Electro-Therapeutics 

Leishman's  Midwifery 

La  Roche  on  Yellow  Fever  . 

La  Roche  on  Pneumonia,  &c. 

Laurence  and  Moon's  Ophthalmic  Surgery 

Lawson  on  the  Eye  ... 

Lehmann's  Physiological  Chemistry,  2  voli 

Lehmann's  Chemical  Physiology  . 

Ludlow's  Manual  of  Examinations 

Ly.ons  on  Fever 

.Medical  News  and  Library     . 

Meigs  on  Puerperal  Fever 

Miller's  Practice  of  Surgery  . 

Miller's  Principles  of  Surgery 

Montgomery  on  Pregnancy    . 

Neill  and  Smith's  Comrendium  cf  Med.  Science 

Nellgan's  Atlas  of  Diseases  of  the  Skin 

Obstetrical  Journal 

Parry  on  ExtraT'terine  Pregnancy 

Pavy  on  Digestion  .... 

Pavy  on  Food 

Parri.sh's  Practical  Pharmacy 
Pirrie's  System  of  Surgery 
Play  fair's  Midwifery       .... 
Quain  and  Sharpey's  Anatomy,  by  Leidy 
Roberts  on  Urinary  Diseases  . 
Ramsbotham  on  Parturition 
Remsi'n's  Principles  of  Chemistry 

Rigby's  Midwifery 

Rodwell's  Dictionary  of  Science     . 

Siimson's  Operative  Surgpry 

Swayne's  Obstetric  Aphorisms 

Sargent's  Minor  Surgery 

Sharpey  and  Qoain's  Anatomy,  by  Leidy 

Skey's  Operative  Surgery 

Slade  on  Diphtheria        .... 

Schiifer's  Histology         .... 

Smith  (J.  L.)  on  Children 

Smith  (H.  H.)  and  Horner's  Anatomical  Atl 

Smith  (Edward)  on  Consumption  . 

Smith  on  Wasting  Diseases  in  Children 

Still6's  Therapeutics        .... 

Slillfe  &  Maisch's  Dispensatory 

Sturges  on  Clinical  Medicin*) 

Stokes  oQ  Fever      ..... 

Tanner's  Manual  of  Clinical  Medicine  . 

Tanner  on  Pregnancy     .... 

Taylor's  Medical  Jurisprudence 

Taylor's  Principles  and  Practice  of  Med   Ji 

Taylor  on  Poisons  . 

Tuke  on  the  Influence  of  the  Mind 

Thomas  on  Diseases  of  Females 

Thompson  on  Urinary  Organs 

Thompson  on  Stricture    . 

Thompson  on  the  Prostate 

Todd  on  Acute  Diseases  . 

Walshe  on  the  Heart 

Watson's  Practice  of  Physic  . 

Wells  on  the  Eye     . 

West  on  Diseases  of  Females 

Weston  Diseases  of  Children 

West  on  Nervous  Disorders  of  Children 

What  to  Observe  in  Medical  Cases 

Williams  on  Consumption     . 

Wilson's  Human  Anatomy    . 

Wilson  on  Diseases  of  the  Skin     . 

Wilson's  Plates  on  Diseases  of  the  Skin 

Wilson's  Handbook  of  Cutaneous  Medicine 

Wiihler's  Organic  Chemistry 

Winckel  on  Childbed 


nsp 


For  "The  Obstetrical  Jouuxal,"  Fivk  Dollars  a  year,  see  p.  23. 


UNIVERSITY  OF  CALIFORNIA  LIBRARY 

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This  book  is  DUE  on  the  last  date  stamped  below. 


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